POSTERIOR INSTABILITY

doi:10.1016/S0030-5898(05)70215-7

Orthopedic Clinics of North America

Volume 32, Issue 3, 1 July 2001, Pages 463-473

https://doi.org/10.1016/S0030-5898(05)70215-7 Get rights and content

Section snippets

PATHOPHYSIOLOGY

Posterior instability is thought to be secondary to 3 types of etiologic processes, the first being a major injury, the second being repetitive minor trauma, and the third is virtually atraumatic.3, 4, 5, 6 Several anatomic conditions also have been associated with this process. Bony anatomic deformities that have been implicated include increased humeral retroversion, glenoid retroversion, and glenoid hypoplasia.7, 8, 9 In the face of normal bony anatomy, the pathoanatomy is often attributed

EVALUATION

In obtaining a patient's history, one must determine the type and mechanism of the event originally producing the instability (eg, major trauma, repetitive minor trauma, or atraumatic3, 4, 5, 22). It is also important to determine whether the patient has a voluntary type of instability or a positional type of involuntary instability. Posterior instability is primarily associated with an initial history of trauma occurring with the arm held in the forward flexed, adducted, and internally rotated

TREATMENT

Initial treatment of instability traditionally remains nonsurgical.4, 9, 10, 19, 20, 39, 40 The emphasis of nonsurgical treatment is on strengthening the rotator cuff, deltoid, and scapular stabilizers. Burkhead and Rockwood³⁹ stress that 80% of patients with an atraumatic cause of shoulder instability, in contrast to 16% of those with traumatic instability, will improve with an exercise program alone. Surgical treatment of posterior shoulder instability should only be considered in those who

THE AUTHORS' PREFERRED OPERATIVE TECHNIQUE

The upper extremity is prepped and draped free in a sterile fashion. The surgical anatomy is outlined on the skin and a standard posterior portal is made. The arthroscope is introduced into the glenohumeral joint through the posterior capsule adjacent to the humeral head. Posterior portal placement of approximately 1 cm lateral to the glenoid is more advantageous than placement immediately adjacent to the posterior labrum.

An arthroscopic examination of the glenohumeral joint is performed to

REHABILITATION

After surgery, the operated extremity is placed in a pillow sling to hold the arm in neutral rotation (Ultra-Sling; Donjoy, Carlsbad, CA). A rigid “hand-shake” orthosis is not required. Before discharge, isometric internal and external rotation and abduction strengthening exercises are begun. On the day after surgery, the patient is instructed to begin active assisted elevation in the scapular plane to shoulder level (salute) and external rotation at the side (handshake position). We advise

RESULTS

A retrospective study of 14 patients first reported the concept of an arthroscopic repair method identical to that described above addressing the posteroinferior capsular redundancy and increasing the glenolabral depth using capsulolabral augmentation.² Posterior capsular laxity was present in all 14 cases and was believed to be the primary pathology. Twelve patients showed some form of labral pathology. Twelve patients had excellent results and 2 had fair results. There was 1 recurrence of

DISCUSSION

Treatment of posterior instability has concentrated on describing and reducing the redundant posterior capsule.4, 5, 16, 19 By contrast, the posterior labrum is an anatomic structure that has been implicated in posterior instability of the shoulder but its pathologic changes and its important stabilizing role have not been fully elucidated.4, 5, 20, 60 Howell was the first to describe the glenoid-labral socket concept. He stated that the labrum contributed approximately 50% to the total glenoid

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Cited by (51)

Does glenoid version affect the post-operative clinical outcome after repair of posterior labral tear: A retrospective study
2024, Journal of Orthopaedics
Posterior shoulder instability and consequent labral tear have been predominantly associated with retroversion of the bony glenoid and chondrolabral version. However, literature concerning the degree of glenoid and chondrolabral version and clinical outcomes following labral repair is scarce.
A retrospective cohort study was undertaken among patients with posterior shoulder instability who had undergone arthroscopic isolated posterior labral repair. The MRI was used to assess the bony and labral variations of the glenoid using the Friedman method and further categorized as either anteverted or retroverted glenoid. American Shoulder and Elbow Surgeons (ASES), Oxford Shoulder Score (OSS), and Single Assessment Numeric Evaluation (SANE) scores were used to evaluate pre- and postoperative clinical outcomes at a minimum follow-up of one year.
33 shoulder MRIs performed at our institution were available for radiographic analysis. Among the 33 shoulders that underwent posterior shoulder capsulolabral repair, 23 were available for clinical follow-up for at least one year (range, 12–108 months). The mean (±SD) labral version and bony version were −3.98 (±5.68) and −2.83 (±5.20), respectively. The mean (±SD) postoperative ASES, Oxford score, and SANE scores for all participants were 84.04 (±14.14), 43.38 (±3.81), and 78.57 (±17.40), respectively. However, the difference in clinical outcomes in patients with anteverted or retroverted glenoid versions was not statistically significant.
Our study concludes a strong correlation between posterior glenohumeral instability and higher degree of glenoid retroversion. Nevertheless, variations in the glenoid version appear to have no significant impact on clinical outcomes.
Level IV, retrospective cohort.
Current Concepts in Assessment and Management of Failed Posterior Labral Repair
2024, Clinics in Sports Medicine
Favorable short-term outcomes of micronized allogenic cartilage scaffold for glenoid cartilage defects associated with posterior glenohumeral instability
2023, Arthroscopy, Sports Medicine, and Rehabilitation
To determine clinical outcomes associated with micronized allogenic cartilage scaffold use for treatment of posterior glenoid cartilage defects at 2 years.
A retrospective analysis of prospectively collected data was performed on a consecutive series of patients who underwent arthroscopic treatment of a symptomatic posterior glenoid cartilage defect with micronized allogenic cartilage scaffold between January 2019 and December 2020. The primary outcome was subjective shoulder value (SSV) at latest follow-up. Secondary outcomes included visual analog scale (VAS), recurrence of instability, and range of motion (ROM).
Seven patients, including 4 in the setting of primary posterior instability and 3 in the setting of recurrent symptoms after arthroscopic posterior glenohumeral stabilization, were included in the analysis with a mean follow up of 2.6 years (range, 2-3.7 years). Statistically significant improvements were seen in SSV (median = 40, interquartile range [IQR] = 40-50 before surgery; vs median = 85, IQR = 67.5-87.5 after surgery; P = .018) and VAS (median = 4, IQR = 4-6.3 before surgery; vs median = 1, IQR = 0-1.5 after surgery; P = .010). No significant differences were seen in ROM. There were no cases of recurrent instability or reoperation.
The use of micronized allogenic cartilage scaffold for glenoid cartilage defects is associated with clinical improvement at 2-year follow-up. This is the case when performed in conjunction with index posterior labral repair when there is a concomitant glenoid cartilage defect or when performed in the setting of persistent pain and mechanical symptoms after prior posterior labral repair.
Level IV, therapeutic case series.
Portal Closure After Segmental Posterior Labral Repair for Posterior Shoulder Instability
2023, Arthroscopy Techniques
Posterior instability, although an uncommon shoulder pathology, is reported most frequently in the athletic population. Arthroscopic repair has emerged as the main surgical treatment modality for posterior instability. However, when compared with arthroscopic repair for anterior instability, the results of this procedure remain suboptimal. The creation of iatrogenic defects in the capsule, due to cannula placement, is a possible culprit. Because these defects typically do not heal satisfactorily, they become stress risers within the capsule itself, which may lead to recurrent instability or an otherwise compromised repair construct. Therefore, we find that routine intraoperative repair of these defects after repair can reduce the risk of injury and possibly improve long-term outcomes. In this article, we illustrate the repair of a posterior segmental tear using all-suture knotless implants with closure of the posterior and posterior-inferior portals after stabilization.
Upper Limb Pain and Dysfunction
2020, Braddom's Physical Medicine and Rehabilitation
Musculoskeletal disorders of the upper limb are common and can involve structures such as bone, joint, ligament, tendon, and muscle. This chapter begins with a description of physical examination maneuvers that can be used to assist with the identification of upper limb pathology. This is followed by a description of the rehabilitation principles that can be used to treat these disorders. The remainder of the chapter discusses the identification and management of upper limb conditions frequently encountered by physiatrists. This information can be applied to accurately diagnose and appropriately treat upper limb conditions, thus maximizing the patient’s functional outcome.
Upper Limb Pain and Dysfunction
2018, Braddom's Rehabilitation Care: A Clinical Handbook

View all citing articles on Scopus

: Address reprint requests to John Antoniou, MD, PhD, FRCSC, Department of Orthopaedic Surgery, McGill University, Jewish General Hospital, Room E-003, 3755 Cote Ste-Catherine Rd, Montreal, Quebec, Canada H3T 1E2

: This article was originally published in the July 2000 issue of Operative Techniques in Sports Medicine.

^*: Department of Orthopaedic Surgery, McGill University, Jewish General Hospital, Montreal, Quebec, Canada. Supported by the E.A. Codman-DePuy Endowment for Shoulder Research at the Department of Orthopaedics, University of Washington, Seattle, Washington

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POSTERIOR INSTABILITY

Section snippets

PATHOPHYSIOLOGY

EVALUATION

TREATMENT

THE AUTHORS' PREFERRED OPERATIVE TECHNIQUE

REHABILITATION

RESULTS

DISCUSSION

First page preview

Arthroscopy

J Shoulder Elbow Surg

J Shoulder and Elbow Surg

Orthop Clin North Am

Clin Sports Med

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

Oper Tech Sports Med

Arthroscopy

Arthroscopy

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

Posterior dislocation of the shoulder

J Bone Joint Surg Am

Recurrent posterior instability (subluxation) of the shoulder

J Bone Joint Surg Am

Recurrent posterior shoulder instability: Diagnosis and treatment

Clin Orthop Rel Res

The treatment of posterior subluxation in athletes

Clin Orthop

An appreciation of posterior instability of the shoulder

Clin Sports Med

Traumatic posterior (retrograde) dislocation of the humerus

J Bone Joint Surg Am

Excessive retroversion of the glenoid cavity

J Bone Joint Surg Am

Posterior shoulder instability: Surgical versus conservative results with evaluation of glenoid version

Am J Sports Med

Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder

J Bone and Joint Surg Am

Static factors affecting posterior shoulder stability

Orthop Trans

Operative management of posterior shoulder instability

Orthop Trans

Tensile properties of the inferior glenohumeral ligament

J Orthop Res

Shift of the posteroinferior aspect of the capsule for recurrent posterior glenohumeral instability

J Bone Joint Surg Am

Recurrent posterior dislocation of the shoulder

J Bone Joint Surg Am

Posterior subluxation of the glenohumeral joint

J Bone Joint Surg Am

Capsulorrhaphy with a staple for recurrent posterior subluxation of the shoulder

J Bone Joint Surg Am