Posterior Labrum Repair: Two-Portal Technique

Abstract

Background:

Posterior labral injuries can cause shoulder pain and instability. Posterior labral tears account for up to 47% of all tears treated arthroscopically. Injuries can result from repetitive microtrauma, recurrent posterior subluxations, or traumatic posterior dislocations. Posterior labral injuries can be reliably repaired with arthroscopic surgery. A systematic review by Delong et al found improved return to play along with lower recurrence rates when repairing these injuries using an arthroscopic approach compared to an open approach.

Indications:

The main indication includes a symptomatic labral tear that has been confirmed by magnetic resonance imaging. Patients commonly report deep posterior shoulder pain and can experience instability symptoms. Positive tests (Kim test, Jerk test, posterior load and shift) and findings of posterior laxity may be seen upon physical examination. Arthroscopic treatment remains the gold standard for labral repairs.

Technique Description:

The surgery is performed using 2 portals, an anterior (viewing) portal and a posterior (working) portal. These portals are used to place the sutures for the repair with knotless anchors. Especially in the case of shoulder instability, the capsulotomy is closed by tying a “blind” arthroscopic knot.

Results:

Through the use of 2 portals, the capsule labral repair is done in a clear, efficient manner. This technique aims to maximize ideal patient outcomes, including quicker return to sport, a lower rate of recurrence, and improved pain and function.

Discussion/Conclusion:

The main advantages of this technique are speed and efficiency. This leads to less postoperative swelling and minimal patient discomfort. Benefits also include its stepwise approach, easy reproducibility, and quality and strength of the labral repair.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

We have no disclosures related to this topic.

Background

Posterior labral injuries can cause shoulder pain and instability. Indications for arthroscopic repair include continued symptoms despite a course of nonoperative treatment. We will outline an injury and workup involving a college football lineman who underwent a posterior labral repair. The surgery is performed with knotless anchors using 2 portals, an anterior (viewing) portal and a posterior (working) portal. Benefits of the technique include its stepwise approach, easy reproducibility, efficiency, and speed, as well as the quality and strength of the repair.

We are presenting a 20-year-old male college football offensive lineman who sustained an acute traumatic event while blocking during a game and felt his left shoulder dislocate and spontaneously reduce.

Indications

On examination, the patient had full range of motion. Strength was 5 out of 5. There was a grade 2 posterior laxity. Significant guarding during the examination made other special tests difficult to assess.

Due to persistent pain and instability present on the examination, as well as the patient's desire to continue to be competitive in college football, we recommended arthroscopic repair and stabilization.

The preoperative evaluation and planning include imaging. Standard radiographs include anteroposterior, Grashey, scapular Y, and axillary views. Magnetic resonance imaging (MRI) is obtained. An MRI arthrogram can be helpful in subacute or chronic cases to help better evaluate labrum or capsular injuries. An arthrogram is typically not necessary in acute cases because there will be a posttraumatic joint effusion. A computed tomography scan is obtained only when there is suspicion of bony glenoid injury.

Technique Description

Instruments include a 45° curved and a 90° straight suture passer loaded with a wire shuttle, as well as a cannula with deployable wings.

For implants, we use 2.9 × 12.5-mm knotless polyether ether ketone (PEEK) anchors and 1.5-mm suture tape. We prefer knotless anchors to prevent rubbing of knots on articular cartilage and other intra-articular structures. These anchors can also be deployed quickly and efficiently. The 3.5-mm PEEK anchors are used in backup situations when purchase is not ideal using a smaller 2.9-mm anchor.

Imaging and radiographs reveal an incidental os acromiale and some irregularities at the posterior glenoid. MRI demonstrates a significant labral tear from the 1-o’clock to 6-o’clock position posteriorly as well as a small reverse Hill-Sachs lesion.

The lateral decubitus position is used. The torso is supported with a bean bag. The arm is held in suspension at approximately 20° of forward flexion and 45° of abduction. Ten to 15 pounds of traction is typically used.

Once we have established our posterior portal, we will establish our anterior portal. We establish this portal just above the subscapularis tendon. Oftentimes with these posterior labral tears, the tear can extend anteriorly, so you need a portal anteriorly where you can address the anterior labrum as well. Then, we are going to place the scope back in the anterior portal and visualize the tear. This was an extensive tear involving the entire posterior labrum. Using a shaver and burr, we are going to prepare the glenoid rim to bleeding bone to stimulate a repair response. Next, we are going to bring in a working canula. This particular cannula has wings that deploy to keep it from pulling out of the shoulder joint while you are working; this is an improvement over screw-in cannulas, which tend to fall out of the joint frequently. Next, we will bring in a rasp and rasp the soft tissues to stimulate a healing response. We are going to bring a drill guide down to the 5:30 position. It is important that this is on the face of the glenoid and not medial on the glenoid. We are going to drill all of our holes first. We find this to be most efficient, and it minimizes the need for multiple instrument passes. We like to place as many anchors as possible. We believe this approach ensures the success of the procedure, similar to anterior labral repairs. These holes are drilled as close as possible to each other without compromising the previous one. In this football player, we are going to place a total of 5 anchors posteriorly. Having your portal positioned correctly to get the correct trajectory is very important. Next, we will bring in the small ablator to clear the soft tissue from the drill holes. This will enable us to identify these holes when it is time for anchor placement. A curved suture passer is then used to take a bite of the capsule inferiorly. We are going to shift it superiorly and then come out underneath the labrum. We are going to shuttle the wire into the joint, remove our suture passer, and then grab the wire with the looper grasping device. The suture is then loaded into the loop of this wire and pulled back through the soft tissues. The anchor is loaded with the suture, tension is placed, and the anchor is deployed. The handle is unscrewed from the anchor and removed. The suture is cut as flush as possible so that we do not have a tag suture, which can rub against your articular cartilage. Here we are visualizing the technique from outside the shoulder. We are going to shuttle in as much of this wire as possible into the joint and then continue to deploy it when we pull out the instrument. My assistant has the free end of the wire in one hand, and we will reach in and grab the other end of the wire with the other hand. We are going to load the suture into the loop in the wire, placing 7 or 8 inches of the suture into the loop, and then it is pulled through the soft tissue. We then load the anchor with the suture. I deploy this anchor with 2 hands. I have an assistant hold the scope. I take out the slack of the suture with one hand and place tension on the suture; with the other hand, I am controlling the driver. The assistant mounts the anchor into place. Appropriate tension on the suture is critical as you deploy the anchor to get a good, solid labral repair. When we grab the capsule, we try to grab a little bit inferior to our drill hole and shift superiorly to decrease the inferior capsule volume and ensure the success of the procedure. This 2-portal technique does not create twists or loops in the suture as long as it is followed. One tip when using this suture passer: we will go through the capsule and aim toward the labrum. Typically, I will hit the glenoid bone and walk it up until I hit the transition to the labrum and then sneak the wire underneath the labrum. As you can see, multiple anchors can be placed quickly and efficiently using this 2-portal technique. As we get to the superior-most anchor, sometimes we will switch to a 90° passer, which gives us a little better trajectory. Again, we will shuttle in as much wire as we can and pull out the instrument; the assistant holds the free end of the wire that is out of the joint. We will reach in with this loop grasper, grab the wire, and pull the loop end out so it can be loaded with suture. Again, this does not result in tangling of the suture when done appropriately. So, we place 5 anchors in this football player, repair the labrum, and tighten the capsule to prevent future instability episodes. For instability cases, I do not like using this posterior capsulotomy, so we are going to close it. We will bring in a corkscrew cannula. I am going to take a suture and load it into a 45° bird beak tie-passing device. We will unscrew the cannula until it is just outside of the capsule, and we will bring in our suture device loaded with the suture and pass it through the capsule inferiorly. I am going to advance the suture as far into the joint as we can and then try and pull the instrument out without pulling our suture out. We will then go through the capsule superiorly, grab the loop of suture, and pull it out of our cannula. Now, we have both limbs of the suture out of the cannula, and we are going to tie a sliding locking knot; this is a Westen knot. We are going to tie this knot blind. We will push the knot down. One assistant holds the cannula, pushes the knot down, flips it, and then places subsequent half-hitches to secure the knot. This suture cutter slides down to the knot and allows you to cut blind, leaving a 2- to 3-mm tag, and this is the completed capsule labral repair with a posterior portal closure.^1-6

It is important to ensure proper patient position with appropriate padding of bony prominences, use of an axillary roll, and avoidance of excessive traction on the arm to minimize the risk of neuropraxia. There can be direct injury to the axillary, musculocutaneous, and suprascapular nerves through accessory portal placement or errant intra-articular instrumentation. Deep infection and thromboembolic events can occur but are rare. Recurrent instability or failure has been reported in 3.5% to 8.1% with arthroscopic repair. Caution should be taken with soft tissue–only repair in patients with significant posterior glenoid bone loss or large reverse Hill-Sachs lesion.

Results

The patient should wear a sling for 6 weeks, except for showering or when working with physical therapy. The patient should also avoid internal rotation, horizontal adduction, or posterior glides for 6 weeks. Closed-chain kinetic strengthening should not be performed for 12 weeks, and heavy lifting, pushing, or pulling should be avoided for 6 months.

Discharge testing is done anywhere between 6 and 12 months postoperatively. The patient needs to demonstrate quality and symmetrical movement throughout the body. This is typically evaluated with a comprehensive movement screen or assessment process. Biomechanical assessment of the athlete's performance is performed to ensure proper mechanics during sports activities.

There are 3 phases. The maximum protection phase is from 0 to 6 weeks. The goal is to protect the repair and promote healing. We want to prevent the effects of immobilization and minimize muscle atrophy. The moderate protection phase is 7 to 12 weeks. The goal is to preserve the integrity of the repair, enhance neuromuscular control, increase strength, and normalize arthrokinematics. The minimal protection phase is from 13 to 24 weeks. We allow the patient to progress to full passive range of motion and active range of motion. We want to improve strength, power, and endurance. There is a gradual return to more demanding functional activities and recreational activities, followed by progression to an interval sports program.

In terms of patient outcomes, Bradley et al, ³ in a large series of 200 patients, reported a 90% return to sport (64% at the same level or higher) after capsulolabral repair for posterior glenohumeral instability with a 6% to 7% failure rate.

A systematic review by DeLong et al ⁴ found improved return to play and lower recurrence rates with arthroscopic repair when compared to open repair. Return to previous level of play was 67.4% and 36.9% for arthroscopic and open repairs, respectively.

Arner et al ² reported on 56 football players who underwent arthroscopic posterior stabilization and showed improved American Shoulder and Elbow Surgeons scores. Of the players, 93% returned to sport and 79% returned at their preinjury level, with a 3.5% failure rate.

Discussion/Conclusion

Potential investigations in this area include the stability of different types of knotless anchors versus knot-tying in the treatment of posterior labral repairs.

We acknowledge the Andrews Institute Research & Education Foundation.

References are listed.