Posterior Labral Tears Research Articles

Serial Changes in Perianchor Cysts Following Arthroscopic Labral Repair Using All-Suture Anchors.

BackgroudChanges in perianchor cysts around the all-suture anchors, which demonstrate distinguished features from the biocomposite anchors, have not been revealed sufficiently. The purpose of this study was to investigate serial changes of perianchor cysts according to the location of the inserted anchor in the glenoid in arthroscopic labral repair using all-suture anchors.MethodsWe enrolled 43 patients who underwent computed tomography (CT) immediately postoperatively and CT arthrogram (CTA) at 1 year or 2 years after arthroscopic labral repair using a 1.3-mm all-suture anchor for recurrent anterior shoulder dislocation with or without a superior labral tear from anterior to posterior and a posterior labral tear. The mean diameter and tissue density (HU) of perianchor cysts were measured depending on the location in the glenoid. Clinical outcomes, labral healing, and redislocation rate were evaluated at 2 years after surgery.ResultsOn functional assessment, the mean American Shoulder and Elbow Surgeons score and Rowe score improved statistically significantly after surgery (from 47.9 ± 14.3 preoperatively to 90.1 ± 9.6 postoperatively and from 45.3 ± 12.4 preoperatively to 92.2 ± 10.1 postoperatively, respectively; p < 0.01). Postoperative redislocations were found in 2 patients (4.7%). In radiological evaluation, the mean diameter of perianchor cysts at postoperative 1 year (3.24 ± 0.65 mm) was significantly larger than the immediate postoperative diameter; however, there was no significant difference between postoperative 1 year and 2 years (3.23 ± 0.57 mm). Tissue density at the center of cysts demonstrated no significant difference between 1 and 2 year postoperatively (107.7 ± 29.8 HU [superior], 99.7 ± 31.7 HU [anteroinferior], and 105.1 ± 25.0 HU [posterior] vs. 109.1 ± 26.1 HU [superior], 106.4 ± 30.3 HU [anteroinferior], and 111.0 ± 32.9 HU [posterior]). The mean diameter of perianchor cysts in the anteroinferior position was largest compared with that in superior or posterior positions.ConclusionsPerianchor cysts associated with all-suture anchors enlarged significantly within 1 year after arthroscopic labral repair regardless of the insertion location in the glenoid. However, the size and tissue density of perianchor cysts were similar at postoperative 1 and 2 years, and satisfactory stability and clinical outcomes were obtained.

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Rare and Nonspecific Injury

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Rare and Nonspecific Injury

The HALP – An unusual triad in shoulder instability

Humeral avulsion of the glenohumeral ligament (HAGL) and posterior labral tears are less common injuries in comparison to Bankart lesion in traumatic shoulder instability. The association of rotator cuff tears with posterior capsulolabral lesions is even rarer. We present an unreported combination of HAGL with posterior labral tear and partial articular infraspinatus tendon avulsion (PAITA). This combination of shoulder injuries (HALP triad – HAGL + posterior labral tear + PAITA) has not been reported so far in English literature. The mechanism of this rare combination of injuries is discussed. The arthroscopic technique for simultaneous repair of this combination of ligament tears is presented.

High Prevalence of Superior Labral Anterior-Posterior Tears Associated With Acute Acromioclavicular Joint Separation of All Injury Grades.

Background:Despite the relatively high number of cases of acromioclavicular joint (AC) separation in the athletic population, optimal clinical outcomes are not achieved in every case. Limited data exist regarding the prevalence of intra-articular glenohumeral pathologies (IAPs) associated with acute AC separation of all injury grades.Purpose:To determine the prevalence of IAPs associated with AC separation, regardless of severity.Study Design:Case series; Level of evidence, 4.Methods:A total of 62 patients (mean age, 37.6 years) with acute AC separation were included in this study; 41 were nonoverhead recreational athletes. All patients underwent magnetic resonance arthrography (MRA) to evaluate for IAPs. Arthroscopic data from patients undergoing surgical treatment were correlated with MRA results.Results:Patients sustained acute AC separation of Rockwood grade 1 (16.1%), grade 2 (46.8%), grade 3 (25.8%), and grade 4 (11.3%). A concomitant IAP was present in 48 of 62 (77.4%) patients and included superior labral anterior-posterior tears (72.6%), anterior labral tears (24.2%), posterior labral tears (4.8%), supraspinatus tears (3.2%), and inferior glenohumeral ligament ruptures (1.6%). There were 18 (29.0%) patients who had a concomitant pathology in >1 intra-articular structure (combined IAPs). Additionally, 71.8% of patients with grade 1 and 2 AC separation had associated IAPs, and 23.1% had combined IAPs. Furthermore, in patients younger than 40 years, 64.0% of those with grade 1 to 3 AC separation demonstrated associated labral pathologies. There was no difference when comparing age or severity of AC separation and the prevalence of concomitant labral tears (P = .36 and .22, respectively).Conclusion:There was a high prevalence of IAPs among patients undergoing MRA after AC separation. While an IAP has been described in association with high-grade AC separation previously, the high prevalence of IAPs in low-grade separation in our study was unexpected and suggests that a thorough evaluation and clinical follow-up for patients with all grades of AC separation may be beneficial.

Combined and Posterior Labral Tears are More Common in a Large Military Population with Operative Shoulder Instability than Previously Reported

Objectives:Shoulder instability is endemic in military and young athletic populations. Anterior shoulder instability is the most prevalent instability in civilian populations, but the unique physical demands placed upon military service members shoulders likely result in a different injury pattern. The purpose of the current investigation was to examine the distribution of labral tears across multiple military medical centers. We hypothesized there would be a higher incidence of posterior and combined labral tears treated operatively as compared to the civilian literature.Methods:The Military Orthopaedics Tracking Injuries and Outcomes Network’s (MOTION) prospective Wounded Ill and Injured Registry (WIIR) was queried for all patients who had undergone a surgical stabilization procedure (CPT 29806, 23455, 23462) from October 2016 to January 2019. Patients with isolated superior labral repairs were excluded. Labral tear location was abstracted from intraoperative data collection forms. Chi-Square analyses (X2) compared the percentage of patients with isolated anterior, isolated posterior, isolated inferior, or combined labral tears between individuals in the current study cohort with a previously reported civilian Norway shoulder instability registry, a reported prevalence at the National Football League scouting combine, and with operative shoulder instability patients at a single military treatment facility. Chi-square analyses also compared differences in labral tear location between males and females. Statistical significance was set a priori at α ≤ 0.05.Results:Three hundred fourteen patients (n=314) were identified who had undergone primary shoulder stabilization during the study period. Three patients were excluded due to insufficient data. Of the 311 remaining patients, 41 (13%) were female, 269 (87%) were male, 1 patient did not report a gender. All 311 patients’ military status was either active duty or active reserve (301 and 10, respectively). Ninety-four patients (30.23%) had isolated anterior labral tears (21 female, 73 male), 76 patients (24.44%) had isolated posterior labral tears (7 female, 69 male), 5 patients (1.61%) had isolated inferior tears, and 136 patients (43.73%) had combined labral tears. The number of posterior and combined labral tears in our data differed from previously reported percentages in the civilian literature (9.90% and 6.93%, respectively; X2(2)=208.94, p<0.00001). We also observed a higher percentage of combined tears than was previously reported from a military institution (18.61%; X2(2)=48.20, p<0.00001). The NFL combine cohort had 31% of players with anterior, 35% of players with posterior, and 35% with combined anterior/posterior labral tears (X2(2)=9.54, p=0.0085). Significantly more females (51.22%) had an isolated anterior labral tear, as compared to males (25.65%; X2(2)=9.25, p=0.009).Conclusion:The rate of posterior and combined labral tears in a military population with shoulder instability is higher than what is reported in the civilian literature, which is in keeping with a previous study at one Army medical treatment facility, although the rate of combined tears was even higher in the current cohort than previously reported in either population. The distribution of tear location is most similar tothat of an NFL combine population, supporting the thought that the military population should be thought of and treated as a population of athletes. Labral tears in females were more consistent with the civilian literature in that they had significantly more isolated anterior tears than posterior orcombined, which significantly differed from males. Military shoulder surgeons should be prepared to address multiple labral tears at the time of shoulder stabilization and be aware of the difference in tear location in females versus males.

Orthopedic Injuries in Professional Surfers: A Retrospective Study at a Single Orthopedic Center.

Literature regarding surfing injuries is scarce and most studies report a high number of minor injuries. Recent literature suggests that musculoskeletal injuries are more common than previously reported. In the mid 2000s, competitive surfing has seen an increase in aerial maneuvers, as they have become more highly rewarded by the judging panel, which may be contributing to a change in injury patterns. Our goal was to evaluate orthopedic injuries in professional surfers. Orthopedic injuries in professional surfers are diverse and have evolved with skill and technology. Retrospective observational study. Level 4 Case Series. Medical records of professional surfers from a single orthopedic center between 1991 and 2016 were reviewed. Injuries sustained while surfing and chronic injuries related to surfing were included. Site of injury, diagnosis, and treatment were recorded along with demographic data. In total, 163 injuries in 86 athletes were recorded. The median injury age was 28.5 years (range 12-62 years) and 92.6% of patients were male. The most frequently injured body parts were the knee (28.2%), ankle (22.1%), and shoulder (19%). Most knee injuries were of the medial collateral ligament at 49%, with 75% of ankle injuries being sprains, and in shoulder, 48% had instability, 42% had a rotator cuff tear, and 35% had a superior anterior-posterior labral tear. Lower extremity injuries primarily affected the surfers' back leg (72.5%). In all, 34.6% of all injuries required surgical intervention and involved shoulder injuries most the time. The most common orthopedic injuries in professional surfers involve the knee, ankle, shoulder, hip, and back. Surfers' rear extremities were preferentially injured which is the extremity responsible for power and torque. Shoulder injuries increased the probability of an operative intervention. Last, overuse injuries (femoral-acetabular impingement, rotator cuffs) occurred in the older surf population compared with more acute injuries (ankle sprains/fractures, anterior cruciate ligament tears) which is also consistent with time to surgery.

Risk Factors for Failure of Nonoperative Treatment of Posterior Shoulder Labral Tears on Magnetic Resonance Imaging.

There are no reports in the literature describing risk factors for failure of nonoperative treatment of patients with posterior labral tears on magnetic resonance imaging (MRI). The purpose of this study is to identify risk factors for failure of nonoperative treatment in patients with an isolated posterior glenoid labral tear identified on MRI only. Patients with posterior labral tears on MRI who fail to improve with nonoperative treatment likely share a constellation of clinical history, physical exam, and radiographic findings. One hundred and fifty-nine active duty military service members under the age of 40 with a posterior labral tear seen on MRI and who were clinically evaluated by a musculoskeletal trained physician were identified. We retrospectively evaluated their records ensuring a minimum of 2 years follow-up after MRI to identify surgical intervention for the posterior labral tear during this time period. Patients were stratified into two groups, those treated with any combination of nonoperative modalities and those treated with posterior labral repair surgery during the 2 years after the MRI. The electronic medical records were reviewed for clinical presentation and physical exam results. We measured multiple radiographic parameters, including glenoid version, size of the tear, and bone loss on MRI. Qualitative and quantitative data were compared between groups using Fisher's exact test and Student's t-test, respectively. This study was conducted under institutional review board approval. Of the 157 patients' shoulders in our study, 52% (n=82) of patients with posterior labral tears underwent nonoperative treatment while 48% (n=75) underwent surgery. The significant risk factors associated with surgery were a history of a specific injury, primary presenting complaint of instability, patient reported history of subluxation, inability to trust their shoulder with overhead activity, decreased strength with weight lifting, positive posterior load/shift exam, positive anterior apprehension, increased osseous glenoid retroversion, increased humeral head subluxation ratio, and anterior labral height (P<0.05). Patients with a chief complaint of pain were much more likely to succeed with nonoperative treatment while those with instability underwent surgery more often. Ten (12.5%) of the surgical procedures included an anterior and posterior labral repair/stabilization procedure. Patients with an MRI confirmed posterior labral tear, which present with subjective complaints and physical exam maneuvers consistent with instability, appear less likely to be treated nonoperatively. Increased glenoid retroversion and posterior humeral head subluxation may also predispose patients toward surgical treatment. Additionally, posterior labral tears may extend into the anterior labrum more frequently than is recognized on MRI.

Glenoid version is associated with different labrum tear patterns in shoulder instability

Previous studies have evaluated glenoid version as a risk factor for anterior and posterior shoulder instability. However, the association of glenoid version with combined anterior-inferior-posterior (>180°) labrum injuries is unknown. The purpose of the present study was to investigate various parameters of glenoid morphology, including version, in >180° labral tears and to compare these values with isolated anterior and isolated posterior tears. Magnetic resonance imaging studies from a consecutive series of shoulder instability patients were reviewed by 3 independent observers to measure the parameters of glenoid morphology including superior-inferior and anterior-posterior diameter, diameter ratio, glenoid version using the glenoid vault method, and percentage of glenoid bone loss using the best-fit circle method. These parameters were compared between patients with anterior (group 1), posterior (group 2), and >180° labral tears (group 3). Interobserver reliability coefficients were calculated for all measurements assessed. There were statistically significant differences for all group comparisons regarding the glenoid version, with group 2 having the most retroversion (19.9° ± 4.71°) followed by group 3 (14.21° ± 4.59°) and group 1 (11.24° ± 5.3°). Group 3 showed the lowest amount of glenoid bone loss; however, the group differences did not reach statistical significance. There was also no statistically significant group difference for the other measured parameters. Interobserver reliability was in the good to excellent range for all measurements. Combined anterior-inferior-posterior labral tears are associated with an increased amount of glenoid retroversion compared with isolated anterior labral tears. Isolated posterior labral tears have the largest amount of glenoid retroversion of all tear patterns.

No difference in outcomes of surgical treatment for traumatic and atraumatic posterior shoulder instability

BackgroundPosterior shoulder instability is a rare pathology and accounts for 2–10% of all shoulder instabilities. The purpose of this study was to compare pain and functional scores following surgical treatment of traumatic and atraumatic PSI. HypothesisThe authors hypothesize that patients with traumatic PSI are at greater risks of residual pain and recurrent subluxation. Material and methodsThe records of 150 patients operated for PSI between 2000 and 2015 at 10 different centers were analysed. Inclusion criteria were symptomatic PSI (subluxation and/or pain) with radiographic signs of posterior glenoid erosion or fracture, posterior labral tears, or reverse Hill Sachs lesions. One hundred and seventeen patients were eligible, of which 84% presented symptoms of subluxation and/or dislocation, and 16% were painful without clinical symptoms of subluxation and/or dislocation. Patients were evaluated at 48±33months (range: 12–159) using the Constant, Walch–Duplay and Rowe scores, with pain on Visual Analogic Scale (pVAS). ResultsCompared to atraumatic PSI, traumatic PSI was more prevalent in men (84.4% vs 61.9%, p=0.031), and tended to have fewer pain symptoms (15.8% vs 23.8%, n.s). Atraumatic PSI was more likely to affect the dominant arm, although the difference was not significant (81.0% vs 59.4%, n.s.). Traumatic PSI did not differ from atraumatic PSI in terms of preoperative lesional characteristics, procedures performed, or postoperative pain and instability. Although these differences were not statistically significant, it is worth noting that traumatic PSI patients experienced more recurrence of instability (15.6% vs 4.8%, p=0.298), and lower pain on VAS (1.5±2.3 vs 2.6±3.0, n.s.) compared to atraumatic PSI. DiscussionFunctional scores did not significantly differ between traumatic and atraumatic PSI after surgery, although traumatic PSI patients tended to have a higher recurrence of instability, while atraumatic PSI patients tended to remain more painful. Level of evidenceIV, retrospective cohort study.

Batter's Shoulder: Clinical Outcomes and Return to Sport.

BackgroundBatter’s shoulder has been defined as an acute posterior subluxation of the lead shoulder during a baseball swing causing a traumatic tear of the posterior labrum. There are limited data correlating repair techniques with return-to-play information but none utilizing standardized outcome measures. The purpose of this study is to examine a case series of patients for postoperative return-to-play and obtain follow-up using standardized outcome measures.MethodsWe retrospectively identified 10 patients with a batter’s shoulder injury. Patients were included if they met the criteria for batter’s shoulder injury. We attempted contact via telephone to complete Western Ontario Shoulder Instability (WOSI) and Disability of Arm Shoulder and Hand (QuickDASH) evaluations. We successfully reached five of the patients. The minimum follow-up was one year and the maximum was 11 years.ResultsAll five patients in our cohort were able to return to play at the previous level without limitation. Patients reported a very low percentage limitation on the WOSI and QuickDASH questionnaires and results are detailed further on. Range of motion (ROM) and strength were not affected.ConclusionBatter’s shoulder is an infrequent cause of posterior labral tearing, leading to a painful swing that can limit sports activity. In our limited series, all patients treated with arthroscopic repair were able to return to play at the previous level, confirming a significantly improved prognosis for a batter’s shoulder injury in contrast to return to play after other causes of posterior labral tears.

WHAT ARE THE PREDICTORS OF POOR PATIENT-REPORTED OUTCOMES FOLLOWING SHOULDER INSTABILITY SURGERY?

Background:Prospectively-collected patient-reported outcomes (PROs) following shoulder instability surgery are limited. Attention has been drawn to standardizing these outcome measures in the adolescent literature.Hypothesis/Purpose:The purpose of this study was to evaluate which factors predict unfavorable PROs following shoulder instability surgery, including a “No” response to the Patient Acceptable Symptom State (PASS) question. We hypothesized that poor outcomes are associated with adolescent males, bone loss, larger labral tears, and articular cartilage injury.Methods:A cohort of patients age 13 years and older undergoing shoulder instability surgery were prospectively enrolled in point-of-care data collection at a single institution across 12 surgeons from 2015-2017. Demographics, ASES and SANE responses, and surgical findings were obtained at baseline. ASES, SANE, and PASS responses as well as revision surgery were queried at least one year post-operatively. Patients with isolated posterior labral tears and prior ipsilateral shoulder surgery were excluded. Regression analyses were performed.Results:A total 268 patients met inclusion criteria of which 201 completed follow-up responses (75%). Non-responders had a greater BMI, smaller proportion of glenoid bone loss, fewer Hill-Sachs lesions, and lower baseline ASES scores by 7.5 points (p < 0.05). Responders’ mean age was 25.5 years and 23% were female. Revision surgery occurred in 2.5% of these patients, and 81% responded “Yes” to PASS. A “Yes” response correlated to mean 31-point improvement in ASES and 34-point improvement in SANE scores. On univariate analysis, “No” responders were more likely to have a smoking history, a larger proportion of glenoid bone loss, and revision surgery (p < 0.05). However, on multivariate analysis, only combined labral tears (anterior/inferior plus superior or posterior tears) and injured capsules were associated with greater odds of responding “No” to PASS and with lower ASES and SANE scores (p ≤ 0.05) (Table 1). Age, sex, Hill-Sachs lesions, and grade III/IV articular cartilage injuries were not associated with variation in any PROs.Conclusion:In this prospective cohort, patients largely approve of their symptom state at one year or greater following shoulder instability surgery. A PASS “Yes” response occurred in 81% of patients and correlated to a clinically and statistically significant improvement in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across PROs, whereas age, sex, and Hill-Sachs lesions were not.Table:Table 1.Significant variables predicting PASS "No" responses, poorer ASES/SANE scores, and revision surgery. P values less than or equal to 0.05 are listed. VARIABLE CATEGORY PASS ASES SANE REVISION SURGERY SexMale (vs Female) Age- BMI- Years of Education- Smoking StatusQuit (vs Never) Current (vs Never)0.033 Baseline VR12 MCS- Glenoid Bone Loss<20% (vs None) >20% (vs None)0.004 Anchor Quantity- Labral Tear LocationSuperior(vs Anterior/Inferior) Combined(vs Anterior/Inferior)0.0500.0230.009 LateralityRight (vs Left) Hill-Sachs LesionYes, Engaging (vs No) Yes, Non-engaging (vs No) Capsule StatusInjured (vs Normal)0.0330.0030.0010.019Humeral and/or Glenoid Articular Cartilage InjuryGrade III/IV Lesion(vs Normal to grade II)

Adolescent Posterior-Superior Glenoid Labral Pathology: Does Involvement of the Biceps Anchor Make a Difference?

Background: Adolescent athletes are at risk of sustaining an injury to the posterior and superior labrum of the glenoid. Limited information is available regarding the outcomes of surgical intervention in this specific age cohort. Purpose: To compare those patients with pure posterior pathology and those with posterior labral tears that involve the biceps anchor (superior labrum anterior-posterior [SLAP] tears) to determine risks for failure in the surgical management. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review was performed on all patients under the age of 19 years over an 8-year period to identify those treated for superior and posterior labral pathology, followed by chart review, radiographic review, and arthroscopic findings. Patient characteristics and other variables were recorded, including cause (traumatic vs atraumatic), activity/sports (overhead vs nonoverhead), involvement of the biceps anchor—crossing the 12-o’clock position (posterior vs SLAP), associated pathologies, outcome scores (Single Assessment Numerical Evaluation [SANE] and Pediatric/Adolescent Shoulder Survey [PASS] scores), and complications. Results: Forty-eight patients (30 boys, 18 girls) with a mean age at surgery of 16.5 years (range, 13.5-19 years) were identified who met criteria, with a mean follow-up of 4.1 years (range, 1.3-6.9 years). Nineteen patients had SLAP tears and 29 patients had posterior tears. All but 2 regularly participated in sports at the time of their injury; of the athletes, 26 (56.5%) played an overhead sport and 20 (43.5%) played a nonoverhead sport. The cause of the injury was traumatic in 25 cases (52.1%) and atraumatic in 23 cases (47.9%). Outcome scores were not significantly different between cause or type of sports played; SANE scores were not significantly different by tear type (mean SLAP score, 88.4 compared with mean posterior score, 80.9; P = .124); but the mean PASS score in the SLAP group was 88.7, compared with 76.2 in the posterior group (P = .005) at final assessment. Only 1 SLAP patient had failed management (5.3%) compared with 5 patients in the posterior-only cohort (17.2%). Conclusion: Posterior SLAP tears have better outcomes and lower failure rates than posterior-only tears in the adolescent population. Posterior-superior labral tears can occur in all sports types with multiple causes, but the only factor that appears to play a role in ultimate outcome is whether the tear crosses under the biceps anchor to the anterior side.

Pathoanatomy of Shoulder Instability in Collegiate Female Athletes

Background: Shoulder instability has been well described in young men; however, few studies have specifically evaluated the pathoanatomy and unique spectrum of injuries in women with shoulder instability. Purpose: To describe the pathoanatomy of operative shoulder instability in a collegiate female cohort. Study Design: Case series; Level of evidence, 4. Methods: The authors performed a retrospective analysis of a consecutive series of female students at a National Collegiate Athletic Association Division I military service academy treated operatively for shoulder instability by a single surgeon between September 2008 and September 2014. Preoperative data collected included patient age, sport, mechanism of injury, number and frequency of dislocations, direction of instability, and co-occurring surgical abnormalities at the time of arthroscopy. Outcome variables included recurrent instability after surgery and need for revision. Results: Thirty-six female student athletes with an average age of 20 years (range, 18-22 years) were included. The majority of instability events were traumatic in nature (69%), and 61% of the total events were subluxations. Rugby was the most common sport for experiencing instability (7 patients), followed by obstacle course training (6 patients). Thirty-two patients (89%) reported multiple instability events, averaging 4 per shoulder. The primary direction of instability was anterior in 26, combined anterior and posterior in 7, and 3 met criteria for multidirectional instability. At the time of surgery, 26 patients (72%) had a Bankart tear, 9 (25%) had a posterior labral tear, and 5 (14%) had superior labrum anterior to posterior tears. Nine patients (25%) were found to have humeral avulsion of the glenohumeral ligament (HAGL) lesions, 7 (19%) had partial-thickness articular-sided rotator cuff tears, and only 1 patient (3%) had evidence of true attritional glenoid bone loss. Hill-Sachs lesions were found in 16 patients (44%). Recurrent instability occurred in 9 patients (25%) following arthroscopic stabilization, and revision surgery was performed in 6 (17%). Conclusion: Shoulder instability in female athletes presents commonly as multiple subluxation events. While soft tissue Bankart lesions were found in numbers equal to those in previous studies include both sexes, bony Bankart lesions were less common in women. Finally, the presence of combined anterior and posterior labral tears and HAGLs in women was more common than previously reported.

Posterior Labral Repairs of the Shoulder Among Baseball Players: Results and Outcomes With Minimum 2-Year Follow-up

Background: There is a paucity of information regarding the treatment of posterior labral tears of the shoulder for baseball players. Reports regarding treatment and postoperative outcomes are more limited than its anterior and superior counterparts. Purpose: To evaluate the clinical presentation, surgical findings, postoperative outcomes, and rate of return to sport after arthroscopic repair of posterior labral injuries of the shoulder among baseball players. Study Design: Case series; Level of evidence, 4. Methods: Retrospective review was performed of baseball players who underwent arthroscopic posterior labral repair between 2009 and 2015 by a single surgeon, with a minimum 2-year follow-up. The group was composed of 32 male patients involved in recreational (6.3%), high school (43.8%), college (31.3%), and professional (18.8%) baseball, with a mean age of 20.5 years. Patients were categorized by chief complaint, clinical findings, surgical findings, and concomitant procedures performed. Pre- and postoperative measures included pain scale, range of motion, American Shoulder and Elbow Surgeons shoulder score, return to play, and patient satisfaction. Results: A variety of tear patterns were identified; 32% involved 90° of the posterior superior labrum; 35% involved the posterior 180°; and 32% involved 90° of the posterior inferior labrum. The dominant mechanism of injury was throwing (34.4%). The most common chief complaint was pain (n = 25, 78%), followed by pain and instability symptoms (n = 6, 18.8%), with only 3% citing isolated sensation of instability. Magnetic resonance imaging clearly identified tear patterns in 75% of cases. American Shoulder and Elbow Surgeons scores significantly improved (P < .0001), increasing on average 30.9 points from the preoperative mean of 65.4 to a postoperative mean of 96.3. No significant range of motion deficits were noted. Tear size and number of anchors utilized did not influence outcomes. Ninety-four percent of athletes returned to play, 61% at previous levels, and 6% did not return. Pitchers had a lower return to previous level of play than position players (41% vs 86%, P = .0113). Conclusion: Arthroscopic treatment of posterior labral tears of baseball players was effective in improving pain and function, resulting in 94% patient satisfaction and 94% return to sport, with 61% returning to previous level of play. Patient presentation is variable, with a majority of patients citing pain rather than instability.

MR arthrographic characterization of posterior capsular folds in shoulder joints.

This was a retrospective study of 604 consecutive shoulder MR images and MR arthrograms obtained from April 2010 to January 2018. Extension in the vertical-oblique plan of the posterior synovial fold on MR arthrography was identified according to the posterosuperior, posteroinferior, superoposterior, and inferoposterior portions. The morphologies of the posterior synovial folds on MR arthrography were divided three subtypes. Morphologic appearances of the posterior labrocapsular complex on conventional MR images were described with four subtypes. A posterior synovial fold in the shoulder joint was identified in 35 of 604 (5.8%) MR arthrography patients. 8 of 35 posterior synovial fold identified on MR arthrography were confirmed at arthroscopy. The most common MR arthrographic type of the posterior synovial fold was triangular-this was detected in 17 of 35 (48.6%) patients. The most common MRI morphology of the posterior labrocapsular complex was doubled posterior labrum. This was detected in 15 of 35 (42.9%) patients. 17 % of patients with posterior synovial folds who were diagnosed with MR arthrography had normal MRI features. The most common localization of the posterior synovial fold was posterosuperior and posteroinferior portions of the posterior labrocapsular structures. The mean of the shortest distance between the posterior synovial fold and the posterior labrum was significantly higher in the positive arthroscopic synovial fold group than in the negative arthroscopic synovial fold group (p = 0.047). Posterior synovial folds, normal capsular anatomic variants, are seen rarely on MR arthrography, and tend to be in the posterosuperior and posteroinferior portions of the posterior capsule. Some types of the posterior synovial fold can mimic a posterior labral tear in conventional MRI. On a direct MR arthrographic image, a posterior capsular synovial fold may be a normal anatomic variant. A fold is more commonly occur in the posterosuperior and posteroinferior capsular portions. The results of our study may allow differentiation of normal variations from abnormalities in patients with symptomatic shoulder joint.

Effect of Posterior Glenoid Labral Tears at the NFL Combine on Future NFL Performance.

Background:Posterior labral injuries have been recognized as a particularly significant clinical problem in collision and contact athletes.Purpose:To evaluate the effect that posterior labral tears have on early National Football League (NFL) performance based on position, associated injuries, and operative versus nonoperative management.Study Design:Cohort study; Level of evidence, 3.Methods:A retrospective review of all participants in the NFL Combine from 2009 to 2015 was performed using medical and imaging reports documented at the combine. Magnetic resonance imaging scans were analyzed for tear location, associated injuries, and evidence of previous surgical interventions. Each player’s NFL draft position, as well as number of games played, number of games started, and snap percentage in his first 2 NFL seasons were collected for performance analysis and were compared with a control group of uninjured counterparts.Results:Players with posterior labral tears were selected significantly later in the draft than those in the control group (draft position, 171.6 vs 156.1, respectively; P = .017). Although no single individual position was significantly affected by posterior labral tears, linemen (both offensive and defensive) with posterior labral tears were drafted significantly later than those without tears (draft position, 164.0 vs 137.7, respectively; P = .018) and had a significantly lower percentage of snaps in their first NFL season (23.8% vs 27.7%, respectively; P = .014). Players who underwent surgical management before the combine had a significantly higher percentage of snaps in their second NFL season than those who were managed conservatively (31.4% vs 22.3%, respectively; P = .022). None of the concomitant injuries recorded (superior labral anterior-posterior tears, glenoid bone loss, reverse Hill-Sachs lesions, rotator cuff tears, reverse humeral avulsions of the glenohumeral ligament, and posterior labral tears combined with anterior tears) significantly affected the draft position, number of games played, number of games started, or snap percentage for the cohort as a whole or any specific position.Conclusion:Posterior labral tears did negatively and significantly affect early NFL outcomes for collegiate football players across several different metrics, especially among linemen. While operative management did not produce significantly superior performance in most outcome measures, it may allow for better longevity of the shoulder and warrants further investigation. Concomitant shoulder injuries did not significantly affect early NFL outcomes in this cohort.

Corrective Posterior Opening-wedge Glenoid Neck Osteotomy for Excessive Retroversion

Excessive retroversion of the glenoid can cause eccentric loading of the glenohumeral joint and may lead to posterior shoulder instability, posterior labral tears, functional impairment, static posterior shoulder subluxation, and progressive glenohumeral arthropathy. For young patients surgical options are limited and include open labral repair and capsular plication, arthroscopic labral repair and capsular plication, or open posterior opening-wedge glenoid osteotomy. Of these, only the osteotomy can correct the glenoid retroversion and recenter the humeral head. Here, we detail our preoperative work-up, the surgical technique and the postoperative protocol for a corrective posterior opening-wedge corrective glenoid osteotomy. Multiple studies have showed that children, adolescents, and young adults with severe glenoid retroversion may benefit from this treatment. This surgery is technically challenging and should have narrow surgical indications. Patients can demonstrate improved radiographic bony architecture of the glenohumeral joint, diminished pain, and improved function.

Prevalence of Shoulder Labral Injury in Collegiate Football Players at the National Football League Scouting Combine.

Background:Labral tears confirmed by magnetic resonance imaging (MRI) are a relatively common injury among collegiate athletes and can influence a player’s ability to compete at the professional level.Purpose:To determine the prevalence of MRI-confirmed shoulder labral injuries in collegiate football players entering the National Football League (NFL) Combine and to further describe these injuries by tear location, player position, history of surgical intervention, and associated concomitant shoulder injuries.Study Design:Descriptive epidemiology study.Methods:Data from 2009 to 2015 were retrospectively collected through review of the injury data registry available to the medical and training staff of all NFL teams following the completion of the NFL Combine. After players with potential labral tears were identified through history and examination, their MRIs were reviewed by 2 fellowship-trained orthopaedic sports medicine surgeons. Players diagnosed with a labral tear confirmed by MRI were separated for further analysis.Results:A total of 2285 players were analyzed for the presence of labral tears at the NFL Combine. Overall, 377 shoulders (in 340/2285 players; 14.9%) demonstrated MRI evidence of labral tear; whereas linebackers had the highest rate of labral tear (19.2%), linemen had significantly higher risk for labral injury in at least 1 shoulder (odds ratio, 1.31; 95% CI, 1.02-1.67; P = .029) compared with nonlinemen. Of the 377 shoulders analyzed, 115 (30.5%) exhibited an anterior labral tear, 131 (34.7%) had a posterior labral tear, and 131 (34.7%) had combined anterior and posterior tears. One hundred twenty (31.8%) shoulders had superior labral anterior-posterior (SLAP) tears. A total of 203 (53.8%) shoulders demonstrated evidence of previous surgical intervention on imaging.Conclusion:Injury involving the labrum is relatively common among participants at the NFL Combine, especially linebackers and linemen. Further investigation is necessary to determine the impact these injuries have on player draft position and NFL performance.

Arthroscopic shoulder posterior stabilisation – How I do it

An arthroscopic shoulder posterior stabilisation is indicated in symptomatic patients with an isolated posterior labral tear. We present our surgical technique and perioperative management.

A case of posterior instability shoulder with Reverse Bankart lesion treated with arthroscopic repair

Glenohumeral instability is a relatively common condition affected in 2% of population, with posterior instability is very uncommon. Glenohumeral instability is usually anterior instability. Posterior instability usually seen in electric shock, seizures, psychosomatic disorders. Redislocation and persistent pain is the main indication for repair of posterior instability due to posterior labral tear. Normally done as open technique by posterior approach, we procede to manage by Arthroscopic stabilization. The posterior capsule, posterior band of the inferior glenohumeral ligament, and posterior labrum provide the greatest support posteriorly. An isolated lesion in any one of these posterior structures often results in unidirectional posterior instability. Arthroscopic repair of posterior labrum has shown good results. The main difficulty with the procedure is gaining appropriate acess to posterioinferior quadrant of glenoid. Additional posterolateral portal which is steep enough angle acces to glenoid is required to avoid multiple accessory portals.