posterior labral repair

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Posterior Labral Tears and Repair

• Definition
  • commonly referred to as a reverse Bankart lesion, or attenuation of the posterior capsulolabral complex

Check out this video testimonial after bilateral labral repairs with biceps tenodesis

• Epidemiology
  • athletes
    • weightlifters (bench press)
    • football linemen (blocking)
    • swimmers
    • gymnasts
    • wrestlers
• Pathophysiology
  • repetitive microtrauma to the posterior capsulolabral complex
    • most common mechanism
    • posteriorly directed force with the arm in a flexed, internally rotated and adducted position
  • glenoid retroversion
    • patients with increased glenoid retroversion (~17°) were 6x more likely to experience posterior instability compared to those with less glenoid retroversion (~7°)
• Associated injuries
  • Kim lesion
    • an incomplete and sometimes concealed avulsion of posteroinferior labrum
• Posterior labrum
  • function
    • helps generate cavity-compression effect of glenohumeral joint
    • creates 50% of the glenoid socket depth
    • provides posterior stability

  OSS Shoulder Dislocation and Labral Tears

  • anatomy
    • composed of fibrocartilagenous tissue
    • anchors posterior inferior glenohumeral ligament (PIGHL)
• Symptoms
  • vague, nonspecific posterior shoulder pain is the most common symptoms
    • worsens with provocative activities that apply a posteriorly directed force to the shoulder
      • ex: pushing heavy doors, bench press, push-ups
  • clicking or popping in the shoulder with range of motion
  • sense of instability
    • less common
  • pain during throwing
    • late cocking phase
• Physical exam
  • posterior joint line tenderness

Dr. Garcia demonstrates his arthroscopic surgical technique for anterior labrum “Bankart” repair.

• provocative tests
• posterior apprehension test
  • arm positioned with shoulder forward flexed 90° and adducted
  • apply anterior support to scapula
  • apply posteriorly directed force to shoulder through humerus
  • positive if patient experiences sense of instability or pain
• posterior load and shift test
  • patient rests arm at their side
  • grasp the proximal humerus and apply a posteriorly directed force
  • assess distance of translation and patient response
    • grade 0 = no translation
    • grade 1 = to edge of glenoid
    • grade 2 = over edge of glenoid but spontaneously relocates
    • grade 3 = over edge of glenoid, does not spontaneously relocate

Dr. Garcia demonstrates his repair technique for posterior shoulder instability

• jerk test
  • arm positioned with shoulder abducted 90° and fully internally rotated
  • axially load humerus while adducting the arm across the body
  • clunk indicates subluxation of the humeral head off the posterior glenoid
    • highly sensitive and specific for a posterior labral tear
• kim test
  • arm positioned with shoulder abducted 90° and forward flexed 45°
  • apply posteriorly and inferiorly directed force to shoulder through humerus
  • positive if patient experiences pain
    • highly sensitive and specific for posteroinferior labral tear
• Nonoperative
  • activity modification, NSAIDs, PT
    • indications
      • first line of treatment

    Dr. Garcia demonstrates his technique for locked posterior dislocation (Modified Mclaughlin Procedure)

    
    • technique
      • rotator cuff and deltoid strengthening
      • periscapular stabilization
• Operative
  • posterior labral repair, capsulorrhaphy
    • indications
      • extensive nonoperative management fails
    • technique
      • arthroscopic and open techniques may be used
      • arthroscopic preferred to open given the extensive posterior surgical dissection required
        • more reliable return to play
      • suture anchor repair and capsulorrhaphy results in fewer recurrences and revisions than non-anchored repairs
• outcomes
  • generally good
  • return to previous level of function in overhead throwing athletes not as reproducible as other athletes
  • failure risk increases if adduction and internal rotation are not avoided in the acute postoperative period

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