Traumatic 270° and 360° labral tears of shoulder – Injury patterns, surgical technique, and mid-term outcomes

Abstract

Aim

Large glenolabral tears (270°–360°) are infrequently reported injuries and can be challenging to manage. This study aims to describe the injury patterns, surgical technique, and midterm outcomes of arthroscopically repaired 270°–360° labral tears.

Methods

Patient data was retrieved from the electronic data records from 2011 to 2021. The patients with arthroscopically confirmed and repaired 270°/360° tears (with or without superior labral anterior posterior lesions) with a minimum follow-up of 24 months were included, and Oxford shoulder instability score and visual analog score (VAS) pain score were recorded prospectively.

Results

Twenty-four patients were included in the study with a mean follow-up of 52.6 ± 24.4 months. The mean pre-operative and final Oxford instability score was 24.8 ± 4.1 and 43.2 ± 1.5 (p < 0.0001). The mean pre-operative and final VAS was 4.95 ± 1.12 and 0.6 ± 0.7(p < 0.0001). Terminal loss of external rotation was seen in five patients with the remplissage procedure. No re-dislocation or instability was reported. All patients returned to pre-injury activity levels.

Conclusion

Pan labral tears can be challenging to diagnose pre-operatively and may result in poor outcomes. Pain can serve as a clinical indicator of larger labral pathology in patients presenting with shoulder instability. A comprehensive understanding of the injury pattern, along with a systematic surgical approach, is essential for restoring adequate joint stability and achieving satisfactory results in the general patient population.

Level of Evidence

IV.

Introduction

Post-traumatic large labral tears are associated with shoulder instability and/or pain. Labral tears have been categorized as anterior (Bankart lesions), posterior (reverse Bankart lesions) and superior labral tears. Combined lesions of the labrum, that is, anterior and posterior labral tears were first reported by Warner et al. ¹ Powell et al. ² then reported the circumferential labral injury and classified it as type IX SLAP (superior labral anterior posterior) tear or panlabral tears.

In 2005, Lo and Burkhart reported cases of triple labral lesions, describing them as anterior, superior, and posterior labral tears. They found the incidence of these injuries to be 2.4%.^2,3 Alpert et al. ⁴ described managing 270° labral tears in individuals with multidirectional instability. Their series included two cases with SLAP tears, which are 360° tears. Subsequently, multiple studies have documented 270° tears involving the inferior labrum, encompassing the anterior, inferior, and posterior quadrants.^5–7

The term “270° tears” has been used interchangeably to describe large, multi-quadrant labral tears involving the anterior, superior and posterior quadrants, or the anterior, inferior, and posterior quadrants.^1,2 This inconsistent terminology has led to ambiguity in the understanding of these injuries. We believe both injury patterns should be considered as 270° tears, as they involve at least three quadrants. A type V SLAP tear with anterior quadrant involvement is an example of a clockwise injury pattern (in a right shoulder). Additionally, this classification may be insufficient in cases with the Buford complex, where the labrum is absent from the 12 to 3 o'clock position.

According to current literature, “pan labral tears” refer to both circumferential tears (360° tears) as well as tears involving the anterior, superior, and posterior quadrants of the labrum (ASP).^{8, 9}

The largest series of 360° tears was reported by Tokish et al., who described good outcomes after arthroscopic repair in a military population of 39 patients. ⁸ Subsequently, Ricchetti et al. presented a series of 44 cases with superior, anterior, and posterior labral tears (ASP), and reported outcomes after arthroscopic repair in general population. ⁹

Available studies on panlabral tears of the shoulder, quote different incidences and techniques of repair. The aim of the study is to describe the injury patterns, and surgical technique and report midterm outcomes of arthroscopically repaired 270°–360° labral tears.

We hypothesize that pain along with instability can be used to suspect large labral tears (270°–360°) and sequential arthroscopic repair of these tears (with or without SLAP) leads to favorable outcomes.

Material and methods

The electronic medical record system was searched for patients diagnosed arthroscopically with 270° labral tears, and 360° labral tears. The terms used to search the database were “large labral tears,” “pan labral tears,” “270° tears,” and “360° tear.”

Inclusion criteria were patients with arthroscopically confirmed and repaired 270°/360° tears with or without SLAP lesion, minimum 24 months follow-up, and patients with recorded pre-operative functional scores. Patients with multi-joint ligament laxity, associated neurological conditions in the same limb, and revision surgery were excluded.

A total of 25 patients were identified in the data records between 2011 and 2021. All patients had at least 270° tear (with or without SLAP lesion). These injuries were diagnosed, surgically treated, and followed up by a single fellowship-trained senior surgeon(R.K.A). Twenty-four patients were finally included. One patient was excluded due to a limited follow-up period.

The patient demographics, history, examination findings, pre-operative pain score (visual analog score (VAS)), functional score (Oxford instability score), radiological and intraoperative findings, number of anchors used, additional arthroscopic procedures, and patient details of subsequent follow-ups were collected. The pre-operative examination, surgical procedure, and follow-up assessment were done by a single fellowship-trained senior surgeon(R.K.A.).

Pre-operative MRI (magnetic resonance imaging) studies with reports of all the patients were obtained for the study.

The individuals treated for pan-labral tears were then followed up at the time of the study through electronic and telephonic methods. Outcome scores were recorded and analyzed using Oxford shoulder instability score (OSIS) and VAS pain score.

Statistical methods

The analysis included profiling of patients on different demographic, clinical, and radiological parameters. Descriptive analysis of quantitative parameters was expressed as mean and standard deviation. Categorical data were expressed as absolute numbers and percentages. Paired Student t-test was used for testing of mean values. Cross tables were generated, and the chi-square test was used for testing associations. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for MRI with respect to arthroscopy as a gold standard. p-value < 0.05 was considered statistically significant. All analyses were performed using SPSS software, version 24.0.

Surgical technique

Under general anesthesia and interscalene block, the patient was positioned in a lateral decubitus position. After preparing the extremity, the standard portals (posterior, mid-glenoid, and anterosuperior) were marked (portal placements are shown in Figures 1 and 2). We kept the posterior portal slightly lateral to get a better approach to the glenoid for instrumentation. Using the 30° scope through the posterior portal, the mid-glenoid portal was secured using the outside-in technique followed by the diagnostic round. Subsequently, the Antero-superior portal (ASP) was established. SLAP tear was repaired at the beginning, followed by the posterior labrum and finally the anterior labrum.

Figure 1.

Portal placement: (a) antero-superior portal and (b) mid-glenoid portal.

Figure 2.

Portal placement: (a) slightly lateral posterior portal and (b) accessory postero-lateral portal.

SLAP lesion repair

Viewing through the posterior portal, the footprint of the biceps anchor was prepared using the mid-glenoid portal. Care was taken to spare the superior capsule. A fiber wire (Arthrex) was passed in a cynch loop fashion around the superior labrum behind the biceps anchor and parked in the mid-glenoid portal. Care was taken to spare the superior capsule as it might lead to post-operative pain. Drilling and labrum security was achieved using a knotless anchor (PushLock (Arthrex)) and cynch loop through the ASP. Figure 3 shows the SLAP tear. The repaired SLAP tear is shown in Figure 4.

Figure 3.

Superior labral anterior-posterior (SLAP) tear.

Figure 4.

Repaired superior labral anterior-posterior (SLAP) tear.

Posterior and antero-inferior labral repair

After completion of the SLAP repair, we switched the scope to the AS portal and secured a 8.25 mm cannula in the posterior portal. To access the inferior labrum an accessory posterolateral portal (7 o’clock portal) was created in an outside-in fashion for the right shoulder (Figure 5). ¹⁰ Using the mid glenoid portal the glenoid was prepared from 10 o’clock to 6 o’clock position using a liberator and shaver in a standard fashion. The posterior and posterolateral portals were also used to prepare the posterior and inferior glenoid. After adequate release, the bites were secured using a lasso through the posterior portal. Using the accessory posterolateral portal the first all-suture anchor is inserted at 7 o’clock position and secured with standard sliding knots. Two more suture anchors are inserted to secure the labrum at 8:30 and 10:30 position using the accessory posterio-lateral portal (Figure 6). The knots are passed through the posterior portal cannula to prevent any soft tissue bridges. After fixation of the posterior labrum, the anteroinferior labrum was liberated through the mid-glenoid portal and released till the subscapularis muscle was visible. Sequential fixation of the anteroinferior labrum was achieved and a south to north shift was attained. The inferior anchor is a knotless cynched 2.9 mm PushLock (Arthrex). The rest of the labrum was secured using all-suture anchors or suture Tak (Arthrex) depending upon the choice made intra-operatively (Figure 7).

Figure 5.

Posterior labral tear.

Figure 6.

Repaired posterior labral tear with three suture anchors (suture Tak-Arthrex).

Figure 7.

Complete 360° labral repair.

The repair location, viewing portal, and working portal for lasso insertion and anchor insertion are summarized in Table 1.

Table 1.

Summarizing repair location, viewing portal, working portal for lasso insertion, and portal for anchor insertion.

Repair quadrant	Viewing portal	Portal for suture Lasso	Portal for anchor insertion
SLAP (superior)	Posterior	Mid glenoid	Antero-superior
Postero-inferior	Antero-superior	Posterior	Accessory postero-lateral
Postero-superior	Antero-superior	Posterior	Accessory postero-lateral
Antero-inferior	Antero-superior	Mid-glenoid	Mid-glenoid

Postoperative care and rehabilitation

In the immediate postoperative period, patients were placed in an arm pouch sling for 6 weeks. Patients were advised passive exercises on the very first postoperative day with external rotation and scapation plane movements to 30° four times a day. Three weeks postoperatively isometrics and scapular control exercises were started. At 6 weeks, the sling was discarded, and the patients were encouraged to perform shoulder stretches as tolerated. Subsequently, as the stiffness improves, strengthening exercises were incorporated for 4–6 months to achieve a full range of motion and strength. Proprioception and sports-specific movements were added as strength improved.

Patients were followed up at 1 week, 3 weeks, 6 weeks, 3 months, and 6 months postoperatively.

Clinical examination included range of motion, instability, apprehension, pain points, and identification of other surgical complications, such as infection and neurovascular deficit. Strength assessments were performed at 3, 6, and 12 months.

The outcome scores were recorded at the time of the study. OSIS and pain score (VAS) were recorded at the time of the final follow-up via electronic forms and telephonic means at the time of the study.

Results

The study finally analyzed the results of 24 patients.

All the patients except one, were under 40 years of age (mean 27.6 ± 6.0) (range 20–41). Only one patient was a female. All patients were right-side-dominant. Surgery was performed on the right side in 14 patients (58.3%). Two patients were professional sports players, and the rest were at the recreational activity level. The mean follow-up of the patients was 52.6 ± 24.4 months (median 55 months)

All patients reported pain and apprehension as their primary complaint. Examination findings revealed low Beighton scores (< 2) in 83% of the patients. Anterior apprehension was positive in all the patients.

The O’briens test was positive in 58% (14/24) of the patients and correlated with intraoperative finding of SLAP tear in 10 patients. One patient had a muscle strength deficit pre-operatively (grade-4/5) due to an infraspinatus tear.

MRI detection was accurate in two patients with 270° tears and three with 360° tears (n = 5/24).

The sensitivity and specificity of MRI for 270° tears were found to be 44.67% (CI: 21.27%–73.41%) and 77.78% (CI: 39.99%–97.19%), respectively.

For 360° tears sensitivity was 33.33% (CI: 7.49%–70.07%) and specificity was found to be 80% (CI: 51.91%–95.67%).

The mean number of anchors used was 6.8 ± 1 (range 5–8). Additional procedures performed were biceps tenodesis in two patients, infraspinatus repair in one patient, posterior labral cyst decompression in two patients, and remplissage procedure as an additional stabilizing procedure in five patients.

The number of anchors used in 360° tears was more than 270° tears. (7.9 ± 0.5 vs. 6.3 ± 0.9) (p  < 0.001).

The mean pre-operative Oxford instability score was 24.8 ± 4.1 (median 26) and the mean Oxford score at the final follow-up was 43.2 ± 1.5 (median 43) (p-value < 0.0001). The mean pre-operative VAS was 4.9 ± 1.1. The pre-operative VAS was more in the 360° tear group 5.9 ± 0.8 versus 4.4 ± 0.91 (p-value  < 0.01). VAS at final follow-up was 0.6 ± 0.7 (median 0.5) (p-value < 0.0001).

There was no significant difference in the outcomes (OSIS) of patients with 270° (42.93 ± 0.96) and 360° (43.3 ± 2.23) tears (p −0.54).

All patients returned to their pre-injury activity levels.

Both the athletes returned to professional sports after full rehabilitation.

The cases requiring the remplissage procedure (n = 5) had a terminal restriction in external rotation in abduction. (AER-2) (range: 10°–15°). Three cases (without remplissage) had terminal stiffness in all planes but without any restrictions in their activities of daily living.

The results of the analysis of the cohort have been described in Table 2.

Table 2.

Results of cohort analysis.

Total number of patients	24
Mean age ± SD (range)	27.6 ± 6.0 (20–41) (years)
Gender (M/F)	23 (95.8%)/1 (4.2%)
Operated side L/R	10 (41.7%)/14 (58.3%)
Tear morphology
270° tears	15 (62.5%)
360° tears	9 (37.5%)
Number of suture anchors (n)
Mean ± SD (range)	6.8 ± 1.0 (5–8)
Median (IQR)	7 (6–7.5)
Additional procedure
Biceps tenodesis	2 (8.30%)
Infraspinatus repair with 1 anchor	1 (4.20%)
Posterior para labral cyst	2 (8.30%)
Remplissage	5(20.80%)
Follow-up (months)
Mean ± SD (range)	52.6 ± 24.4 (12–86)
Median (IQR)	55 (34.5–70.0)
Outcomes
Oxford score	Pre-operative	Post-operative
Mean ± SD (range)	24.8 ± 4.1	43.1 ± 1.5 (40–48)
Median (IQR)	26	43 (42–43)
		(p-value 0.0001) (95% CI)
VAS	Pre-operative	Post-operative
Mean ± SD (range)	4.9 ± 1.1	0.6 ± 0.7 (0–2)
Median (IQR)	5	0.5 (0–1.0)

SD: standard deviation; IQR: interquartile range; VAS: visual analog score.

The subgroup analysis is presented in Table 3.

Table 3.

Sub group analysis of 270 and 360 degree tear groups.

	360° tears		270° tears		p-value (CI (95%))
N	9		15
Side (R, L)	4,5		10,5
	Mean	SD	Mean	SD
Age (years)	28.4	7.3	27.1	5.3	0.615
EUA grade	3.1	0.7	2.9	0.5	0.487
Beightons score	1.3	2	0.267	1.0	0.097 (p-value < 0.001 Levene's test)a
Number of anchors	7.6	0.5	6.3	0.9	< 0.001
Follow-up	55	15.9	51.2	28.8	0.7
Events of dislocation	10.9	6.8	6.9	8.2	0.2
Pre-op VAS	5.9	0.8	4.4	0.91	< 0.001

a Levene's test for variance.

Discussion

360° and 270° labral tears are infrequently reported injuries. 360° labral tears are complete detachment of the labrum from the margins of the glenoid, with no functional part of the labrum intact.^{8, 11}

According to our understanding, 270° tears are triple quadrant injuries ranging from 12 o’clock to 9 o’clock (clockwise) or 12 o’clock to 3 o’clock (counterclockwise) (both for the right shoulder) (Figures 8 and 9).

Figure 8.

270° tears are triple quadrant injuries from 12 o’clock to 9 o’clock (clockwise) (right shoulder).

Figure 9.

270° tears are triple quadrant injuries from 12 o’clock to 3 o’clock (counter-clockwise) ( right shoulder).

The incidence of 270 ° tears has been reported as 2.4% and 3.6%.^{3, 9} This study found the combined incidence of 360° and 270° was 9.7%, in a single surgeon's(R.K.A) practice over a span of 10 years at a tertiary care center.

All the patients in the series presented with traumatic index events. The Beightons score was 1.3 (±2) versus 0.2 (±1) when comparing the 360° group and 270° group (p-value −0.001). The chief complaint was pain with a history of dislocation at presentation. Similar findings were reported in the series by Tokish et al. ⁸ Additionally, Kim et al. have reported that patients with panlabral tears report more pain, than patients with isolated Bankart lesion. ¹²

In this series, the mean pre-op VAS was 4.9 ± 1.1. This is comparable to other similar series.^{8, 12}

In our series, the pain score (VAS) was higher in 360° tears as compared to 270° tears. When these results were compared to other series with anterior labral tears, the 360° tears exhibited a higher VAS pain score.^13,14 In our study, most of the patients had multiple dislocation events, the highest being 30 and the lowest being a single event. No event of posterior dislocation was reported, contradictory to the findings of other larger series. ⁸ A likely reason might be the limited ability of the patient to discriminate between anterior and posterior dislocation. Anterior apprehension was present in all the patients. O’Briens test was positive in 50% of the patients with 360° tears. Recently, the O’Briens test has been demonstrated to be of more diagnostic value for postero-inferior labral tears than for other labral tears including SLAP lesion.^{15, 18}

As per earlier reports, MRI has limited reliability in these injury patterns. ¹⁶ The sensitivity of MRI has been reported to be 21.3% by Ricchetti et al. ¹⁷ In this study MRI reported sensitivity of 46.67% (CI: 21.27%–73.41%) for 270° tears and 33.3% in 360° tears (CI: 7.49%–70.07%). More radiological studies are warranted.

In our experience lateral decubitus position is more favorable for these extensive injuries. The position aided better visualization and examination of the posterior labrum, using the antero-superior portal.

During the surgical procedure, the biceps-labral complex was repaired first, followed by the posterior labrum, and finally the anterior labrum. In our opinion fixing the SLAP lesion first provides a fixed point to proceed with the circumferential repair. A similar philosophy was demonstrated by Rao et al. reporting favorable results. ¹⁸ Earlier studies emphasized repair of the posterior labral tear, followed by antero-inferior and finally superior tear was addressed.^1,8,9 Any difference in outcomes is yet to be established.

Beginning with an identifiable attachment site for the SLAP lesion, the labrum can be anatomically restored to achieve the desired concavity compression and application of the circle concept.^{11, 19}

Also, fixing the antero-inferior labrum first, especially with the south-to-north shift, might produce excessive buckling in the antero-superior quadrant (around 2 o’clock).

It was also observed that a south-to-north shift, following a restored posterior labrum, allowed adequate tensioning of the inferior-glenohumeral ligaments. This is desirable in patients with multiple dislocations and plastic deformation of the soft tissues. ²⁰

As we could address the incidental additional pathologies (paralabral cyst, biceps pathology, rotator cuff injury, and Hill-Sach lesion) associated with pan labral tears, we agree with the comment by Mazzocca et al. regarding the arthroscopic management of this condition. ²¹

A summary of previous studies is presented in Table 4.

Table 4.

Previous literature on pan labral tears.

Study	Year	Follow-up (months)	Patients (n)	Mean age (years)	Functional outcome scores	Avg. no. of anchors	Sequence of Labral repiar
Tokish et al. 8 (360° tears)	2009	31.8	39	25.1 (range 17–38)	VAS-pain- 1.1 ± 1.5 SANE-88.5 ± 11.1 ASES-89.6 ± 11.1	7.1	Posteiror → anterior → Superior
Lo and Burkhart 3 (270° tears)	2005	12.7	7	25 (range 17–36)	Satisfaction-full	–	–
Mazzocca et al. 21 (270° tears)	2011	28	19	23 (range 15–45)	Carter Rowe-92 ASES-91 SANE-91 SST-11 WOSI-302 Constant-95	6(median)	Posterior → Inferior → Anterior
Berthold et al. 7 (270° tears)	2021	22.7 ± 35.4	21	27.1 ± 9.6	ROWE-88.7 ASES-91.8 SST-11.2 SANE-21.5 WOSI-220.6	6.3 ± 0.6	Posterior → inferior → anterior
Pounder et al. 5 (270° tears)	2020	42.2 ± 16.5	25	28.9 ± 7.4	ROWE-80.6 SIRSI-61.8 VAS-2.2 SSV-86.4	6.2 ± 1.3	Superior → posterior → inferior → anterior
Ricchetti et al. 9 (270° tears)	2012	42 (16–78)	44	32 (15–55)	ASES-90.1 ± 17.7 Penn Shoulder Score-90.2 ± 15.3	7.9 (5–12)	Anterior → posterior → superior

VAS: visual analog score; SANE: single assessment numeric evaluation; ASES: American shoulder and elbow surgeons score; SST: simple shoulder test; WOSI: Western Ontario shoulder instability index; SIRSI: shoulder instability-return to sport after injury score; SSV: subjective shoulder value.

Tokish et al. reported six complications in 41 shoulders with circumferential tears: two re-dislocations, two cases of postoperative stiffness, and two SLAP tears, for which all patients had a second surgery ⁸ Ricchetti et al. studied the outcomes of 270° tears (triple labral) and identified 13 complications, including six episodes of shoulder stiffness; however, only three (7%) patients required additional or revision surgery. One patient required shoulder replacement after developing glenohumeral arthritis after 3 years. ⁹ Pounder et al. identified only one recurrent subluxation with no dislocations or revision surgery in their 25 patient cohort of 270° labral tears. ⁵ In the 10-year follow-up study by Berthold et al., three (14.2%) complications were identified. One patient had a recurrent subluxation after a handball injury. Another patient had continued instability and a third had a repeat traumatic dislocation, both of which required revision surgery (14.2% failure rate). ⁷ No redislocation/resurgery is reported in this study.

This may be because the study group was not homogenous in terms of level of sports activity with limited athletes. The athletes reported a timely return to sports without any discomfort. Addressing the large Hill Sachs in 20.8% (n = 5) of the cases with remplissage might have also provided additional dynamic stability.

The study has a few strengths. It is a single surgeon study with standardized pre-operative assessment, rehabilitation and surgical approach making it more homogeneous. The outcomes were prospectively recorded and assessed. The pre-operative and post-operative functional score assessment provides an objective comparison.

This study has several limitations. It is a retrospective study. Outcomes were assessed using a single patient-reported score (OSIS). The arthritic changes were not recorded in all the cases, which might have provided more evidence regarding the degenerative changes in this injury pattern. The functional demands were not homogenous in the study population. Finally, the current study included mid-term follow-ups and long-term assessment was not possible. Studies with longer follow-ups will be beneficial.

Conclusion

Pan labral tears can be challenging to diagnose pre-operatively and may result in poor outcomes. Pain can serve as a clinical indicator of larger labral pathology in patients presenting with shoulder instability. A comprehensive understanding of the injury pattern, along with a systematic surgical approach, is essential for restoring adequate joint stability and achieving satisfactory results in the general patient population.