Beach-Chair Versus Lateral Decubitus Positioning for Arthroscopic Posterior Shoulder Labral Repair: A Retrospective Comparison of Clinical and Patient-Reported Outcomes

"Bankart Repair and Beyond. Anticipating difficulties and managing complications. Current concepts"

Anterior shoulder instability is a frequent complaint among young athletes. The Arthroscopic Bankart Repair (ABR) is a highly successful technique for restoring the native anatomy after a capsular and labrum avulsion lesion from the glenoid. The procedure has a low complication rate, and a large proportion of patients return to sports at the same pre-injury level. As a reliable surgical technique, ABR is rarely associated with intraoperative complications, but surgical details are critical to avoid struggling during the procedure. Postoperative complications, such as neurovascular injuries, infections, and stiffness, are significant concerns. In the long term, ABR's most common complications are the recurrence of instability and shoulder arthritis after the procedure. This article focuses on 1) the complications of ABR and the critical measures to prevent them, 2) additional techniques that can enhance primary ABR outcomes or address recurrences and failures, and 3) best practices to prevent shoulder arthritis after ABR.

Midterm Outcomes After Revision Posterior Labral Repair in Active-Duty Military Patients

Background

Active-duty military service members experience posterior glenohumeral instability at a rate that far outpaces that of nonmilitary populations. While the outcomes after primary posterior labral repair (PLR) in this population are promising, the outcomes after revision procedures remain poorly described.

Purpose

To report midterm outcomes after revision PLR in a population of active-duty military patients.

Study Design

Case series; Level of evidence, 4.

Methods

Patients who underwent revision PLR from January 2011 through December 2018 by the senior surgeon with a minimum of 5 years of follow-up were deemed eligible for inclusion. Preoperative and postoperative outcome scores for the visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), and the Rowe instability score as well as the rates of return to active duty and sports and the rate of recurrent instability were collected and pooled for analysis.

Results

Overall, 21 patients with a mean follow-up of 77.95 ± 39.54 months met inclusion criteria and were available for analysis. At midterm follow-up, patients who underwent revision PLR experienced significantly improved VAS (from 7.3 ± 1.8 to 2.9 ± 2.4), ASES (from 49.5 ± 12.6 to 79.7 ± 16.7), SANE (from 45.0 ± 14.8 to 80.2 ± 20.3), and Rowe (from 37.6 ± 9.4 to 79.4 ± 24.7) scores. Over 80% of patients also achieved the minimal clinically important difference for these outcome measures; however, only 52% to 62% of patients achieved the Patient Acceptable Symptom State. The return-to-sport rate was 66.67%, and the return to active-duty rate was 80.95%.

Conclusion

While patients who underwent revision PLR experienced improvements in outcomes and a decrease in pain on average, they exhibited rates of return to active-duty and sports that lagged behind those demonstrated in a previous cohort that underwent a primary procedure. Furthermore, the achievement of clinically significant outcomes after revision PLR was less consistent compared with that after primary PLR.

Basics of Shoulder Arthroscopy Part IV: Diagnostic Arthroscopy in the Lateral Decubitus Position

Shoulder arthroscopy is a versatile method for treating a variety of shoulder pathologies in a minimally invasive manner. Typically, it is performed with the patient positioned in a beach-chair or lateral decubitus position with the latter being conventionally preferred for shoulder instability work given the use of traction and creation of a distracted joint. This allows ideal visualization and accessibility of the anterior, inferior, and posterior aspects of the glenoid, labrum, and axillary pouch. Despite the apparent advantages, the lateral decubitus position comes with its own technical challenges. Many of these may stem from surgeon training, experience, and level of familiarity with the positioning and arthroscopic view. This Technical Note demonstrates a reproducible and teachable method for efficient and effective diagnostic shoulder arthroscopy in the lateral decubitus position, along with presenting its associated advantages and disadvantages.

Posterior Labral Repair Using Knotless "All-Suture" Suture Anchors

Isolated posterior instability is well described but relatively uncommon, accounting for less than 10% of all shoulder instability cases. When nonoperative management fails, surgical outcomes demonstrate improved patient-reported outcomes with a high level of return to sport. Knotless suture anchor and "all-suture" suture anchor technology are now available and used for instability procedures in the shoulder. This technical description describes knotless "all-suture" suture anchor fixation for isolated posterior labral tears.

Posterior Shoulder Instability in the Military and Athlete: An Evidence and Experience-Based Treatment Approach

Background:

Recognition of posterior glenohumeral instability has increased in young, athletic populations, leading to evolution in operative approaches to management. As with anterior instability surgery, successful treatment for these challenging injuries is dependent on understanding the key principles of pathology and restoration of the functional anatomy.

Indications:

Operative management of posterior glenohumeral instability is indicated for recurrent instability events or persistent pain refractory to physical therapy in the setting of posterior labral pathology with or without bone loss.

Technique:

In this video article, we present our approach to operative management of posterior glenohumeral instability in a young, athletic population, as developed through extensive experience in military and athlete populations and supported by research. Our approach to posterior glenohumeral instability is to restore the functional anatomy of the bone, labrum, and capsuloligamentous static restraints. We consider concomitant pathology and bone loss as components of these restraints that need to be restored to achieve a stable, painless shoulder. Using standard portals and tools, we prepare the glenoid and mobilize the labrum. When present, large osseous lesions can be restored using allograft distal tibia. We then repair and superiorize the inferior labrum, taking care to create a secure buttress against translation by positioning anchors at the edge of the chondral surface and everting the interior flap of tissue. If capsular pathology is present, this is also addressed. In the setting of significant posterior glenoid bone loss, we reconstruct the osseous support with a distal tibial allograft, which we perform arthroscopically and augment with labral repair. Using these techniques, surgeons can expect a low overall failure rate. In our young, highly active population, we observed 17.2% failure by 5 years, although this is dependent on multiple factors including age and bone loss.

Discussion:

Outcomes for posterior glenohumeral instability can be excellent with both nonoperative and operative treatments. When operative intervention is pursued, it is important to critically evaluate the anatomy, place portals considerately, and functionally restore the damaged structures.

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.

Anatomic Osteochondral Allograft Reconstruction for Concomitant Large Hill-Sachs and Reverse Hill-Sachs Lesions

Glenohumeral instability causing bipolar bone loss is increasingly being recognized and treated to minimize recurrence. Large Hill-Sachs and reverse Hill-Sachs lesions of the humerus must be addressed at the time of surgery to prevent recurrent dislocations and restore the native anatomic track. For patients with epilepsy, locked dislocations may create defects that must be addressed with bony procedures, including osteochondral allograft reconstruction as soft-tissue remplissage may not adequately addresses the magnitude of the bone loss. Osteochondral allografts have been successfully used to address bony defects ranging from 20% to 30% of humeral bone loss whereas shoulder arthroplasty is indicated for larger defects where the native anatomy can no longer be restored. In this Technical Note, we present a technique to address concomitant large Hill-Sachs and reverse Hill-Sachs lesions.