Arthroscopic management of posterior instability

From Diagnosis to Decision-Making: A Systematic Review of the Management of Reverse Hill-Sachs Lesions after Posterior Shoulder Dislocations

(1) Background: The aim of this study is to describe all of the possible surgical procedures that intend to treat the McLaughlin lesion (or Reverse Hill-Sachs) in posterior shoulder dislocation. (2) Methods: Google Scholar, Pubmed, and Embase were used as databases in our research. Studies reporting the results of posterior shoulder dislocations surgically treated with procedures addressing the humeral lesion were evaluated. The studies reporting results after fracture-dislocation and multidirectional instability were excluded. (3) Results: A total of 16 studies were included in our review for a total of 207 shoulders with a mean age of 41.7 years that were evaluated at a mean of 62.1 months. The Modified McLaughlin procedure and the Graft procedures were the most commonly performed. No statistically significant difference was found between the two at the evaluation of the clinical score. (4) Conclusions: Our review highlights the importance of a correct diagnosis and an accurate surgical treatment choice based on the surgeon's experience and on the patients' characteristics.

Jeor JD, Trasolini NA, Waterman BR. Batter's Shoulder: All-Knotless Posterior Labral Repair With Retensionable Anchors for Treatment of Batter's Shoulder

Batter's Shoulder is a unique injury that may be associated with recurrent microtrauma followed by acute subluxation of the humeral head on the posterior glenoid edge, leading to posterior labral tears. Early identification of this injury is critical, as it may be treated with conservative nonsurgical treatments prior to labral tear onset. If conservative treatment fails and pain persists, surgical options include arthroscopic fixation to reapproximate the posterior labrum to the glenoid and restore capsular tension. Previous studies have shown the benefit of using knotless suture anchors in arthroscopic shoulder fixation. This technical note demonstrates that Batter's Shoulder is a unique injury associated with posterior labral tears of the shoulder and provides a contemporary method of arthroscopic fixation of a posterior labral tear using retensionable knotless all-suture anchors.

Accuracy of MR arthrography in the detection of posterior glenoid labral injuries of the shoulder

OBJECTIVE

The purpose of this study is to evaluate the accuracy of MR arthrography in detecting isolated posterior glenoid labral injuries using arthroscopy as the reference standard.

METHODS

MR arthrograms of 97 patients with isolated posterior glenoid labral tears by arthroscopy and those of 96 age and gender-matched controls with intact posterior labra were reviewed by two blinded radiologists for the presence and location of posterior labral abnormalities. The sensitivity and specificity of detection of posterior labral tears were calculated as well as the prevalence of associated pathologies. Medical records were reviewed for demographics, history and direction of shoulder instability, and prior surgery.

RESULTS

Posterior labral pathology was detected by MR arthrography with sensitivities of 76% and 84% for readers 1 and 2, and a specificity of 88% for both readers. Kappa value for interreader agreement was 0.91. Twenty-two of twenty-three (96%) tears isolated to the posteroinferior quadrant on arthroscopy were correctly identified on MRI. Commonly associated pathologies included paralabral cyst (38%), humeral fracture (7%), and glenoid fracture (2%). Fifteen of ninety-seven (16%) patients with posterior tears on both arthroscopy and MRI had glenoid rim deficiency on imaging versus no patients with intact posterior labra (p < 0.001). Forty of ninety-seven (41%) patients with posterior tears on arthroscopy had a history of posterior instability versus none without posterior tears. There was no significant difference in tear length on MRI between those with a history of instability and those without (p = 0.56).

CONCLUSION

MR arthrography is accurate in detecting posterior glenoid labroligamentous injuries.

Evaluation, Treatment, and Outcomes of Batter's Shoulder

PURPOSE OF REVIEW

This article reviews the incidence of batter's shoulder, the relevant biomechanics that predispose the lead shoulder to a posterior instability event, the evaluation and workup of posterior labral injury, the surgical technique for arthroscopic posterior labral repair, the postoperative rehabilitation process, and the clinical outcomes and return to sport after treatment of batter's shoulder.

RECENT FINDINGS

New epidemiological studies have demonstrated the relatively low incidence of batter's shoulder at the professional baseball level with 85% of the injured players successfully returning to the sport with nonoperative management. However, recent studies have reinforced the limited historical literature that players requiring surgery are able to return to their prior sport at a high level. Batter's shoulder is a subtype of posterior glenohumeral instability caused by the significant forces experienced by the lead shoulder during the baseball swing. Although an uncommon injury, batter's shoulder is a source of significant time away from competition. In patients who do not improve with nonoperative management, arthroscopic posterior labral repair can reliably return players to sport. Future research studies should consider opportunities for injury prevention.

Batter's Shoulder: Clinical Outcomes and Return to Sport

Background

Batter’s shoulder has been defined as an acute posterior subluxation of the lead shoulder during a baseball swing causing a traumatic tear of the posterior labrum. There are limited data correlating repair techniques with return-to-play information but none utilizing standardized outcome measures. The purpose of this study is to examine a case series of patients for postoperative return-to-play and obtain follow-up using standardized outcome measures.

Methods

We retrospectively identified 10 patients with a batter’s shoulder injury. Patients were included if they met the criteria for batter’s shoulder injury. We attempted contact via telephone to complete Western Ontario Shoulder Instability (WOSI) and Disability of Arm Shoulder and Hand (QuickDASH) evaluations. We successfully reached five of the patients. The minimum follow-up was one year and the maximum was 11 years.

Results

All five patients in our cohort were able to return to play at the previous level without limitation. Patients reported a very low percentage limitation on the WOSI and QuickDASH questionnaires and results are detailed further on. Range of motion (ROM) and strength were not affected.

Conclusion

Batter’s shoulder is an infrequent cause of posterior labral tearing, leading to a painful swing that can limit sports activity. In our limited series, all patients treated with arthroscopic repair were able to return to play at the previous level, confirming a significantly improved prognosis for a batter’s shoulder injury in contrast to return to play after other causes of posterior labral tears.

Risk of neurological injury in posterior bone block surgery for recurrent glenohumeral instability: a cadaveric study

INTRODUCTION

Recurrent posterior glenohumeral instability poses a challenge for treatment. Bone block procedures have been advocated in cases where a bony defect is present. However, these techniques are not free of complications due to the proximity of neurovascular structures. The aim of this study is to measure the distance to the axillary and suprascapular nerves at the different steps of the procedure.

MATERIALS AND METHODS

Ten frozen human cadavers were used. The bone graft was prepared and placed on the posterior aspect of the glenoid, where it was fixed with two K-wires in different positions: parallel to the articular surface and with 20° of medial angulation. The distance from the entry and exit points of the K-wires to the axillary and suprascapular nerves was measured.

RESULTS

At the exit point, mean distance from the superior K-wire to the axillary nerve was 4.4 mm in the neutral position and 14.4 mm when medially angulated (p = 0.01) and 2.6 mm and 11.5 mm, respectively, for the inferior K-wire (p < 0.01). No differences were found at the entry point (p = 0.7 and p = 0.3). For the suprascapular nerve, mean distance to the entry point of the superior K-wire was significantly greater when it was inserted with 20° of medial angulation than when placed in neutral position (p = 0.04). No differences were found for the inferior K-wire (p = 0.35).

CONCLUSION

Posterior bone block surgery should be performed taking into consideration the possibility of axillary nerve injury anteriorly at the exit point of the K-wires. Wire and screw insertion parallel to the glenoid articular surface may reduce the risk, while increased wire or screw medial angulation with respect to the glenoid surface may heighten risk.

LEVEL OF EVIDENCE

Not applicable (cadaveric study).

Clinical Outcomes and Return to Sport After Arthroscopic Anterior, Posterior, and Combined Shoulder Stabilization

Background:

Glenohumeral instability is a common abnormality, especially among athletes. Previous studies have evaluated outcomes after arthroscopic stabilization in patients with anterior or posterior shoulder instability but have not compared outcomes between groups.

Purpose:

To compare return-to-sport and other patient-reported outcomes in patients after primary arthroscopic anterior, posterior, and combined anterior and posterior shoulder stabilization.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent primary arthroscopic anterior, posterior, or combined anterior and posterior shoulder stabilization were contacted at a minimum 2-year follow-up. Patients completed a survey that consisted of return-to-sport outcomes as well as the Western Ontario Shoulder Instability Index (WOSI), Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Sur’geons (ASES) score, and Shoulder Activity Scale.

Results:

A total of 151 patients were successfully contacted (anterior: n = 81; posterior: n = 22; combined: n = 48) at a mean follow-up of 3.6 years. No significant differences were found between the groups with regard to age at the time of surgery or time to follow-up. No significant differences were found between the groups in terms of WOSI (anterior: 76; posterior: 70; combined: 78; P = .28), SANE (anterior: 87; posterior: 85; combined: 87; P = .79), ASES (anterior: 88; posterior: 83; combined: 91; P = .083), or Shoulder Activity Scale (anterior: 12.0; posterior: 12.5; combined: 12.5; P = .74) scores. No significant difference was found between the groups in terms of the rate of return to sport (anterior: 73%; posterior: 68%; combined: 75%; P = .84).

Conclusion:

Athletes undergoing arthroscopic stabilization of anterior, posterior, or combined shoulder instability can be expected to share a similar prognosis. High patient-reported outcome scores and moderate to high rates of return to sport were achieved by all groups.

Arthroscopic Management of Posterior Instability due to "Floating" Posterior Inferior Glenohumeral Ligament Lesions

The "floating" posterior inferior glenohumeral ligament (floating PIGHL) is an uncommon cause of posterior shoulder instability. This pathologic lesion, defined as detachment of both the origin of the PIGHL (posterior Bankart lesion) and insertion of the of the PIGHL from its humeral head insertion site, often results in significant and persistent shoulder instability symptoms. An effective surgical technique for arthroscopic repair of a floating PIGHL lesion is described and demonstrated.

Arthroscopic Repair of Posterior Glenohumeral Capsular Rupture With Concomitant Anterior and Posterior Labrum Detachment

Posterior glenohumeral capsular rupture is a rare cause of posterior glenohumeral instability. With advances in imaging and arthroscopic techniques, diagnosis and treatment of posterior glenohumeral instability are becoming more common in practice. We present a technique for arthroscopic repair of a posterior glenohumeral capsular rupture with concomitant anterior and posterior labrum detachment. Arthroscopic fixation was facilitated by use of a 70° arthroscope through an anterior viewing portal to allow accurate placement of the posterior portal in preparation for knot tying. This arthroscopic technique resulted in a successful outcome.

The isolated inferior glenohumeral labrum injury, anterior to posterior (the ILAP): A case series

INTRODUCTION

We describe the presentation, exam findings, surgical repair techniques, and short-term outcomes in a series of patients with isolated inferior labral tears.

MATERIALS AND METHODS

A retrospective chart review was performed at a large academic medical center. Isolated inferior labral tears were defined as between the 4 o'clock and 8 o'clock position of the glenoid as determined by direct arthroscopic visualization. Tears that were smaller were also included but were required to cross the 6 o'clock point, having anterior and posterior components. Patients were excluded if they had any other pathology or treatment of the shoulder. 1-year follow-up was required.

RESULTS

Of the 17 patients who met inclusion criteria for review, 12 were available for a minimum 1-year follow-up. Average total follow-up for patients to complete the phone interview/Oxford Shoulder Instability Score (OSIS) was an average of 37.7 months (range: 16-79 months). Postoperatively, all reported symptom improvement or resolution since surgery. The mean preoperative pain on a scale of 0-10 was 6.3 (range: 0-10). Mean postoperative pain on a scale of 0-10 was 2.25 (range: 0-5). Eleven of 12 patients (91.7%) had returned to the level of activity desired. The mean OSIS was 41.4 (median: 43; range: 27-47). Eleven of 12 patients (91.7%) had good or excellent scores. Ten of 12 patients (83.3%) had a feeling of stability in the shoulder. All 12 patients reached were satisfied with the procedure and would undergo surgery again in a similar situation.

CONCLUSIONS

We have presented our series of patients with isolated inferior labral injury, and have shown that when surgically treated, outcomes of this uncommon injury are good to excellent and a full return to sports can be expected.

Revision posterior shoulder stabilization

BACKGROUND

Revision arthroscopic posterior glenohumeral stabilization requires a thorough understanding of the static and dynamic stabilizers of the glenohumeral joint. The evaluation of these patients is complex but critical given the variety of possible underlying lesions.

METHOD

We reviewed the literature surrounding recurrent and revision posterior instability biomechanics, etiology, evaluation, treatment, and outcomes. We also reviewed our own database of posterior instability cases and isolated revision procedures to review our own outcomes and to highlight overall concepts.

DISCUSSION/CONCLUSION

Although other authors have argued that performing a revision procedure indicates for an open procedure and osseous augmentation, our experience has been that revision posterior stabilization arthroscopic soft-tissue repair alone may be indicated in selected patients. After identification of posterior glenoid bone loss/effective retroversion and mechanical failure of prior repairs, the majority of the patients with recurrence of posterior instability likely have either recurrent or persistent labral pathology or patulous capsules with occult multi-directional instability primarily manifesting in the posterior direction. These patients are best served with capsular shift, reefing, and plication, often requiring 180-270° repair and 4 or greater suture anchors. Because of significant heterogeneity in the clinical outcomes reported to date further research will be necessary to define the clinical outcomes in revision posterior stabilization.

The posterolateral portal: optimizing anchor placement and labral repair at the inferior glenoid

The Bankart lesion is considered the critical lesion in anterior shoulder instability, in which the anteroinferior glenoid labrum separates from the glenoid rim. Technical advances in arthroscopy have ushered in a shift from open to arthroscopic Bankart repair. When one is performing an arthroscopic Bankart repair, proper portal placement is critical for success in labral preparation and anchor placement. Frequently, standard anterior portals are insufficient for inferior glenoid anchor placement and suture shuttling. The posterolateral portal-located 4 cm lateral to the posterolateral corner of the acromion-simplifies and improves anchor placement, trajectory, and anatomic capsulolabral repair of the inferior glenoid. We present our preferred technique for capsulolabral repair of the inferior glenoid.

'Batter's shoulder': can athletes return to play at the same level after operative treatment?

BACKGROUND

Batter's shoulder has been defined as posterior subluxation of the lead shoulder during the baseball swing. However, it is unclear whether or how frequently patients may return to play after treatment of this uncommon condition.

QUESTIONS/PURPOSES

We therefore determined the rate of return to play after operative treatment for Batter's shoulder and whether ROM was restored.

METHODS

We retrospectively reviewed the records of 14 baseball players diagnosed with Batter's shoulder. Four played professionally, six were in college, and four were in varsity high school. The average age was 20.3 years (range, 16-33 years). All had physical examinations and MRI findings consistent with posterior labral tears involving the lead shoulder. Treatment involved arthroscopic posterior labral repair (n = 10), débridement (n = 2), or rehabilitation (n = 2). The minimum followup was 18 months (average, 2.8 years; range, 18-64 months).

RESULTS

Eleven of 12 surgically treated patients returned to their previous level of batting at an average of 5.9 months after surgery. The one patient who was unable to return to play also had an osteochondral lesion of the glenoid identified at surgery. Players typically returned to hitting off a tee at 3 months and to facing live pitching at 6 months postoperatively. All patients regained full internal and external ROM as compared with preoperative data.

CONCLUSIONS

Batter's shoulder is an uncommon form of posterior instability in hitters affecting their lead shoulder. Most athletes are able to return to play at the same level after arthroscopic treatment of posterior capsulolabral lesions.

LEVEL OF EVIDENCE

Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.