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Abstract & Commentary
Synopsis: Arthroscopic repair of the posterior capsulolabral complex is an effective means of eliminating symptoms of pain and instability associated with posterior Bankart lesions of traumatic origin.
Source: Williams RJ 3rd, et al. Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med. 2003;31:203-209.
Posterior shoulder instability may arise from a posterior Bankart lesion (detachment of the posterior capsule and labrum below the glenoid equator), posterior capsular laxity, or both. A variety of open surgical procedures for posterior instability have been described with good results. However, the role of arthroscopic repair in the treatment of posterior shoulder instability remains poorly defined. The present study evaluates the clinical results of arthroscopic repair of posterior Bankart lesions in patients with traumatic posterior shoulder instability.
Williams and associates retrospectively reviewed 27 shoulders in 25 patients (all male, mean age, 28.7 years) who underwent arthroscopic repair of a posterior Bankart lesion using bioabsorbable tacks (Sure-Tac, Acufex Microsurgical, Andover, Mass). All 26 patients recalled a specific traumatic event (athletic injury in 20 of 27 shoulders) leading to the onset of their symptoms. The mean interval from injury to surgical repair was 2.4 years (range, 2 weeks to 16 years). Patients with concomitant anterior instability or those who had undergone previous or concurrent capsular stabilization were excluded. Patient evaluation at follow-up consisted of a physical examination, radiographs, functional scores (L’Insalata shoulder rating score and SF-36 physical and mental component score), and subjective satisfaction questionnaire.
The mean interval to follow-up was 5.1 years (range, 2.0-11.7 years). All patients had full range of motion in the affected shoulder preoperatively and at follow-up. Prior to the procedure, 23 of 27 shoulders (85%) demonstrated a positive posterior load and shift test that improved to 2 of 27 shoulders (7%) after the arthroscopic repair. Preoperatively, supine stability testing revealed gross posterior instability (2+ or greater, 0-3+ scale) in 14 of 27 shoulders (52%). All shoulders improved to an instability grade of 1+ or less after the repair. Two patients had isolated external rotation weakness (grade 4/5). One of these 2 patients had undergone a subsequent open posterior stabilization after the arthroscopic repair. The mean follow-up L’Insalata and SF-36 physical and mental scores were 90 ± 13.9 (range, 50-100), 50.4 ± 7 (range, 37-61), and 53.9 ± 9 (range, 31-63), respectively. Subjective symptoms of pain and instability were eliminated in 24 patients (25 shoulders [92%]). Overall satisfaction was high, with 96% reporting the procedure to be successful and willing to undergo the surgery again.
Two patients (8%) failed the arthroscopic posterior Bankart repair. One patient underwent a successful open posterior stabilization 12 months after the initial repair due to persistent instability. The second reported mechanical symptoms with sports activities 8 months after the arthroscopic repair. MRI revealed a persistent posterior labral detachment and the patient underwent labral debridement 13 months after the initial repair and was subsequently able to return to full sports activity.
Comment by Brian J. Cole, MD, MBA, and Stephen J. Lee, BA
Due to the difficulty in diagnosis and management, posterior shoulder instability remains a challenging clinical entity for orthopedic surgeons. The findings of this study suggest that arthroscopic repair of the posterior capsulolabral complex is an effective means of treating posterior shoulder instability in a specific patient population—those with a history of a distinct traumatic episode, presence of a posterior Bankart lesion, and minimal posterior capsular laxity. We agree with Williams et al’s acknowledgement that a successful posterior stabilization requires a complete evaluation of all etiologic factors, including the degree of capsular laxity and competency of the posterior band of the inferior glenohumeral ligament complex. We also believe that with the addition of suture plication, coexisting pathology can more easily be addressed, and possibly success rates will improve in a larger patient population amenable to arthroscopic treatment compared to isolated treatment with a single-point fixation device.
Dr. Cole, Assistant Professor, Orthopaedic Surgery, Rush Presbyterian Medical Center, Midwest Orthopaedics, Chicago, IL, is Associate Editor of Sports Medicine Reports. Mr. Lee is a Research Fellow in Sports Medicine at Rush Presbyterian Medical Center.