Arthroscopic Posterior Labral Repair With Capsulorrhaphy and Anterior Interval Closure: Surgical Technique

Abstract

Background:

Posterior glenohumeral instability, though less common than anterior instability, accounts for a substantial portion of operatively managed shoulder instability in active populations. Arthroscopic posterior capsulolabral repair restores the soft tissue structures of the shoulder to reduce recurrent instability. However, the described surgical techniques vary greatly. We present a reproducible technique for improving the quality and volume of tissue incorporated in the repair and using interval closure to further reduce recurrent instability rates.

Indications:

Arthroscopic posterior capsulolabral repair is indicated for athletes and high-demand patients with recurrent instability who do not have significant glenoid or humeral bone loss. This can include first-time dislocators participating in high-risk sports and vocational activities.

Technique Description:

Shoulder arthroscopy is performed in the lateral position with a posterior portal, a Wilmington portal, and 2 anterior portals. Viewing from the anterosuperior portal and working through the Wilmington portal, the capsulolabral complex is elevated from the posterior and inferior glenoid using electrocautery, followed by a liberator knife. The native labral footprint on the glenoid is prepared for repair using a hooded burr. Sutures are passed through the capsulolabral tissue with a self-retrieving device via the anteroinferior portal. A drill guide is advanced through the Wilmington portal, and the tissue is sequentially secured with knotless anchors along the posterior glenoid. The resulting construct forms a robust restraint to posterior instability. An arthroscopic rotator interval closure is then performed for further stability.

Results:

Outcomes of arthroscopic posterior capsulolabral repair are generally acceptable, with reported return-to-play rates >90% and recurrence rates <6%. Nevertheless, some concerns persist regarding the ability to return to sport at preinjury levels postoperatively.

Discussion/Conclusion:

Arthroscopic posterior capsulolabral repair with interval closure is an effective operation for addressing recurrent posterior shoulder instability. This technique optimizes the quality and volume of soft tissue incorporated into the repair and offers an additional layer of stability via interval closure.

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 present our surgical technique for arthroscopic posterior labral repair with capsular shift and anterior interval closure by Dr John Kopriva, Dr Vishal Desai, and Benjamin King, with senior author Dr Spero Karas, from Emory University in Atlanta, Georgia.

Disclosures relevant to this talk are listed here. Additionally, all authors have an up-to-date list of disclosures on the American Academy of Orthopaedic Surgeons website.

In this video, we review posterior labral injuries and resulting posterior shoulder instability, using a common case presentation. We review physical examination maneuvers. We discuss treatment considerations and when to proceed with an arthroscopic procedure; our preferred surgical technique, including technical pearls; and our postoperative protocol.

Background

Similar to anterior pathology, posterior labral injuries and instability can result from a traumatic dislocation. ⁷ However, repetitive microtrauma also plays a role, presenting in athletes such as football linemen, powerlifters, and throwers.^7,10

When nonoperative efforts to restore stability fail, arthroscopic repair of the posterior labrum can be performed, barring significant glenoid or humeral bone loss.^1-3,6,8,9

We present a 16-year-old male high school football offensive lineman who has had >1 year of worsening left shoulder pain and function. On the field, he notes issues blocking with outstretched arms, and in the weight room, he can no longer bench press. Although he has not experienced a dislocation event requiring formal reduction, he endorses frequent episodes of subjective instability. Despite >6 months of therapy efforts, he continues to feel his performance is limited by the left shoulder.

On examination, the patient was neurovascularly intact with preserved motion and strength in all planes. However, the patient did have apprehension on the posterior stress test, a positive jerk test, and a positive posterior drawer test.

We demonstrate our preferred provocative examination maneuvers in the following videos: the load and shift, the posterior drawer, the posterior stress apprehension, and the jerk test.

Returning to our case, in-office radiographs demonstrated a concentric joint with no appreciable osseous defects.

Subsequent magnetic resonance imaging confirmed a posterior inferior labral tear without bone loss on the glenoid or humerus.

The patient elected to proceed with an arthroscopic posterior labral repair.

Technique Description

For arthroscopic shoulder instability procedures, we prefer the lateral position. The operative arm is abducted 15°, and 15 lbs. of in-line traction is placed. Additionally, lateralizing traction is placed proximally adjacent to the axilla.

A posterior portal is established closer to the posterolateral edge of the acromion for improved visualization and versatility for potential instrumentation. Then, under direct visualization, 3 additional portals are created: a Wilmington portal with a large 8.25-mm cannula, an anterior superior viewing portal with a 6-mm cannula, and an anterior inferior working portal with a large 8.25-mm cannula.

Diagnostic arthroscopy is performed, which confirms a posterior inferior labral injury without significant glenoid bone loss or arthritis.

Switching our camera to the anterior superior portal, the torn labrum is elevated from the posterior inferior glenoid, first using electrocautery via the Wilmington portal. This includes creating a small landing zone for the repair on the face of the posterior glenoid, typically no wider than the 4-mm tip.

Subsequently, a liberator knife is used to elevate the injured labrum further from the glenoid. This is taken to the 6-o’clock position.

The landing zone is gently prepped using a 5-mm hooded burr, taking care to protect the labral tissue. Finally, an arthroscopic shaver is used to clean any remaining damaged tissue from the posterior and inferior aspects of the glenoid.

For the first suture passage, a self-retrieving device is inserted through the anterior inferior portal with a trajectory toward the inferior aspect of the repair. The self-retrieving device allows reliable passage of a nonabsorbable suture through a substantial segment of tissue.

Care is taken to cross the glenohumeral joint without damaging the cartilage by either rotating the device or closing the jaws.

Subsequent nonabsorbable sutures are passed in a similar fashion via the anterior inferior portal. As has been well established, we always attempt to place at least 3 anchors.

Sutures are shuttled out of the Wilmington portal in preparation for anchor placement.

We place the drill guide through the Wilmington portal for our first anchor on the posterior inferior face of the glenoid. With the anchor engaged in the drill tunnel, the tissue is advanced onto the face of the glenoid by tensioning the suture.

Each subsequent anchor is tensioned in a similar fashion as we work our way up the posterior glenoid, creating a wall of posterior capsular-labral tissue.

Our preferred anchors are biocomposite with both interference fixation and an internal locking mechanism, creating robust resistance to pull out.

Upon review of the repair, more fixation is needed superiorly.

A fourth stitch is passed using a curved suture-passing instrument.

Once the nonabsorbable suture is shuttled through, the anchor is placed in the same fashion as before.

The completed posterior labral repair with a substantial wall of capsulolabral tissue is seen here.

For the anterior interval closure, both anterior cannulas are removed. A straight suture passer pierces the capsular tissue and continues through the superior edge of the subscapularis tendon.

Superiorly, a bird beak grasper is used to pierce the capsule superior to the prior portal site, avoiding the biceps tendon, to retrieve the PDS suture. A nonabsorbable No. 2 braided suture is then passed.

Tensioning of the interval space can be seen here. To avoid loss of adducted external rotation, care should be taken to avoid excessively medial suture passage, and the suture should be tied with the humerus in external rotation.

Results

Postoperatively, patients are placed into a gunslinger brace for 6 weeks.

We recommend 3 phases of therapy: passive, active, and resistive. During weeks 5 and 6, patients may come out of the sling for therapy, working on passive range of motion, in plane with the scapula. Active, or phase 2, occurs during weeks 7 and 8 with active range of motion exercises. Phase 3 begins in week 9 with band and lightweight rotator cuff and periscapular strengthening exercises. Bench press and similar exercises are avoided until 4 months postoperatively. No contact sports are permitted for at least 5 months.

Discussion

Closure of the rotator interval is employed in select patients with posterior instability. Closing this anterosuperior tissue further protects against posterior inferior subluxation. We typically perform this additional step in patients with hypermobility, contact athletes, and those with an inferior sulcus that persists in external rotation, as well as revision cases. The rationale for interval closure is based on biomechanical studies, citing reductions in both anterior and posterior translation of the glenohumeral joint.^4,5

Reported outcomes after arthroscopic posterior labral repair note high return-to-sport rates >90%, with revision rates <6%. ⁶ However, limitations have been noted with return to the same level of sport or activity. ⁶