Abstract
Posterior glenohumeral capsular rupture is a rare cause of posterior glenohumeral instability. With advances in imaging and arthroscopic techniques, diagnosis and treatment of posterior glenohumeral instability are becoming more common in practice. We present a technique for arthroscopic repair of a posterior glenohumeral capsular rupture with concomitant anterior and posterior labrum detachment. Arthroscopic fixation was facilitated by use of a 70° arthroscope through an anterior viewing portal to allow accurate placement of the posterior portal in preparation for knot tying. This arthroscopic technique resulted in a successful outcome.
Causes of posterior glenohumeral instability include injury to the posterior labrum, posterior capsule, posterior band of the inferior glenohumeral ligament (PIGHL), and rotator interval.1, 2, 3 Injuries to the posterior capsule and PIGHL have previously been defined by the West Point classification system as posterior humeral avulsion of the glenohumeral ligament (PHAGL), posterior bony humeral avulsion of the glenohumeral ligament, or floating posterior-inferior glenohumeral ligament (PHAGL with concurrent detachment of the posterior glenoid-labrum complex resulting in a freely floating inferior glenohumeral ligament).4 There is one previous report of a traumatic posterior midcapsular rupture leading to posterior glenohumeral instability.5 Identification and management of these injuries can be difficult because of their variable presentation, findings on advanced imaging, and unpredictable response to conservative measures.1, 2, 3, 4, 5 The purpose of this article is to present a technique for repair of a posterior glenohumeral midcapsular rupture along the PIGHL, which presents with recurrent glenohumeral instability and detachment of the anterior and posterior labrum. An arthroscopic repair using 2 portals with percutaneous placement of suture and anchors is presented.
Surgical Technique
Preoperative Planning
Before surgery, an examination under anesthesia is necessary to assess range of motion, grade anterior and posterior humeral translation on the glenoid, and reveal any other clicks or signs of pathology. Examination of the contralateral extremity should be performed for comparison. This technique is performed with the patient in the lateral decubitus position using a beanbag positioner. The operative extremity is prepared and draped in a standard fashion and secured into a Spider2 Limb Positioner (Smith & Nephew, Andover, MA).
Diagnostic Arthroscopy
Initially, an anterior viewing portal is established through the rotator interval to assess the posterior capsular injury and to achieve precise placement of the posterior portal. Initial diagnostic arthroscopy is completed with a 30° 4.5-mm arthroscope from the anterior viewing portal. A 70° 4.5-mm arthroscope is then used to visualize the inferior extent of the posterior capsular injury (Fig 1). The linear rent in the posterior capsule extends from the 7-o'clock position at the humerus posteriorly through the axillary pouch along the course of the PIGHL. Posterior labrum detachment with edge fraying is identified from the 6- to 9-o'clock position with associated synovitis and Outerbridge grade 2 chondral damage6 at the posterior margin of the glenoid and corresponding area of the humeral head. A Bankart-style detachment of the anterior-inferior labrum is also present with no associated chondral damage (Fig 2).
Fig 1.
Right shoulder magnetic resonance arthrogram and corresponding arthroscopic findings. (A) An axial section of the magnetic resonance arthrogram at the inferior glenohumeral joint shows a tear of the posterior glenohumeral capsule with the superior portion of the capsular tear (white arrow) and the inferior portion of the torn capsule (black arrow) visible. (B) Corresponding arthroscopic image of a right shoulder in the left lateral decubitus position. A 70° arthroscope from the anterior viewing portal visualizes the posteroinferior joint capsule with the inferior portion of the torn posterior glenohumeral capsule (black arrow) and superior leaflet of the torn posterior capsule (white arrow) and underlying infraspinatus muscle belly (asterisk). (G, glenoid; H, humeral head.)
Fig 2.
Right shoulder magnetic resonance arthrogram and corresponding arthroscopic findings. (A) An axial section of the magnetic resonance arthrogram of the glenohumeral joint shows increased signal within the anterior area of the glenoid-labrum complex (arrow). (B) Corresponding arthroscopic image of a right shoulder in the left lateral decubitus position. A 70° arthroscope from the posterior viewing portal visualizes the anterior-inferior glenoid and labrum with an arthroscopic probe showing the anterior-inferior glenoid labrum detachment from the 5-o'clock (asterisk) to 3-o'clock position (arrow). (G, glenoid; H, humeral head.)
A posterior working portal is established by spinal needle localization just medial to the capsular rent. A closed cannula is placed over a switching stick with the opening kept extracapsular at the margin of the tear. Diagnostic arthroscopy is completed from the posterior portal.
Posterior Glenohumeral Capsule Repair
The camera is placed anteriorly for viewing with a 70° lens. Through the posterior cannula, a SutureLasso (Arthrex, Naples, FL) is used to capture the inferior portion of the capsular tear and pass a nitinol wire loop (Arthrex) through the tissue, which is held with a percutaneously placed spinal needle. A tissue penetrator is then inserted through the cannula to capture the superior leaflet of the tear and pull the nitinol wire loop extracorporeal so that a FiberWire (Arthrex) can be passed through the ends of the torn capsule. The FiberWire is then tied for a side-to-side repair of the capsule. The knots are on the outer surface of the capsule and tied within the cannula to avoid any soft-tissue bridge (Figs 3 and 4, Video 1).
Fig 3.
Arthroscopic images of a right shoulder in the left lateral decubitus position with a 70° arthroscope from the anterior portal viewing the posterior capsule tear (white arrows) before (A) and after (B) side-to-side suture closure. The frayed edge of the detached posterior labrum is indicated by the black arrows. (G, glenoid; H, humeral head.)
Fig 4.
Posterior capsular repair. The 70° arthroscope is placed in the anterior viewing portal with the lens directed toward the capsular tear. The posterior cannula is placed through the infraspinatus muscle belly within the extracapsular layer at the edges of the torn posterior capsule. Knot tying is performed within this cannula.
Posterior Labrum Reconstruction
After posterior capsular repair, by use of a switching stick, the cannula is moved into a more typical posterior “soft spot” position7 through the same skin incision. Debridement of the posterior labrum is performed along with preparation of the glenoid rim using a combination of the arthroscopic shaver and rasp. A SutureLasso is again used to pass a nitinol wire loop through the posterior capsule and labrum. A FiberTape (Arthrex) is shuttled through the tissues with the nitinol wire loop and fixed at the 8-o'clock position of the glenoid with a 2.5-mm PushLock knotless anchor (Arthrex) (Fig 5, Video 1).
Fig 5.
Arthroscopic image of a right shoulder in the left lateral decubitus position with a 70° arthroscope from the anterior portal viewing the posterior glenohumeral capsule (PC) after debridement and knotless suture anchor repair of the detached posterior capsule–labrum complex (arrow). (G, glenoid; H, humeral head.)
Bankart Repair
After repair of the posterior capsule and posterior labrum, the stability of the shoulder should again be assessed. If anterior instability remains, anterior capsulolabral reconstruction may be considered. The camera is then placed posteriorly for viewing the anterior pathology (Fig 2). The number and type of anchors (knotless v knotted) to be used are based on the extent of anterior-inferior labrum detachment and surgeon preference. Either knotted or knotless anchor repair can be performed through a cannula in the anterior portal (Video 1).
Posterior Portal Closure
In cases of posterior shoulder instability, closure of the posterior portal is an important step. The arthroscope is placed in the anterior portal for viewing, and the cannula is positioned just outside of the posterior portal. An absorbable suture is passed through each leaflet of the portal using a tissue penetrator. This suture is tied within the cannula for a side-to-side repair (Fig 6, Video 1).
Fig 6.
Arthroscopic images of a right shoulder in the left lateral decubitus position with a 70° arthroscope from the anterior portal viewing the posterior portal. (A) Absorbable suture has been passed through the inferior leaflet of the portal (black arrow), and a tissue penetrator is passed through the superior leaflet of the tear (white arrow) to pull the suture through the cannula. (B) The posterior portal has been closed (arrow). (G, glenoid.)
Postoperative Protocol
Postoperatively, the patient is placed into a sling with an external-rotation pillow for 4 weeks. At 2 weeks, the patient begins a passive range-of-motion protocol. At 4 weeks, active range of motion is directed by a physical therapist until full motion is achieved. This is followed by light strengthening for 6 weeks and then sport-specific training at 12 weeks postoperatively.
Discussion
Posterior glenohumeral instability may be due to a vast array of pathologic lesions to the posterior capsule, posterior labrum, PIGHL, or bony deficiency of the glenoid or humeral head. Lesions of the posterior capsule and PIGHL can occur at any point along the PIGHL or at the humeral or glenoid attachments.8, 9 Early reports of posterior midcapsular tears leading to posterior instability did not provide a technique for surgical repair.8, 10 Several more recent case series have described arthroscopic techniques for repair of the floating PIGHL lesion and have reported successful outcomes.11, 12, 13, 14 Precise posterior portal placement is an important step in these cases and should be conducted under direct visualization from the anterior portal.14
One previous case report of a posterior midcapsular rupture reported good results after a similar arthroscopic suture repair at 5 months' follow-up.5 Moreover, Rothberg and Burks15 reported excellent outcomes in 2 patients at 1 year after arthroscopic suture repair of an anterior capsular rupture similar to the technique described in our report. In contrast to the reports by Shah et al.5 and Rothberg and Burks, this is the first report of preoperative magnetic resonance arthrogram findings of posterior capsular rupture confirmed with arthroscopic findings.
With advanced imaging and arthroscopic diagnostic techniques, the pathology of posterior glenohumeral instability has become better defined over the past several years. Although posterior midcapsular rupture remains a rarely reported injury pattern, it should be considered as a cause of posterior glenohumeral instability. The described technique highlights the importance of following a diagnostic algorithm that is relevant to all cases of posterior glenohumeral instability. When arthroscopic surgery is indicated in these patients, establishing the anterior viewing portal for diagnostic arthroscopy is an important step to guide the surgical repair based on the location and extent of pathology. Arthroscopic repair of posterior midcapsular rupture as outlined in this article can result in a successful outcome and return to sport. The arthroscopic steps are outlined in Table 1, and pearls and pitfalls are shown in Table 2.
Table 1.
Steps of Posterior Capsular Repair
| 1. Anterior viewing portal established for diagnostic arthroscopy |
| 2. Posterior portal established by spinal needle localization |
| 3. Closed cannula placed through muscle layer and kept extracapsular adjacent to posterior capsule tear |
| 4. SutureLasso used to capture inferior leaflet of capsule |
| 5. Tissue penetrator used to capture superior leaflet of capsule and pull nitinol wire loop extracorporeal |
| 6. No. 2 FiberWire passed through both ends of capsule tear |
| 7. FiberWire tied within cannula |
| 8. Any additional pathology addressed |
| 9. Posterior viewing portal closed with absorbable suture |
Table 2.
Pearls and Pitfalls
| Pearls | Pitfalls |
|---|---|
| The anterior viewing portal should be established first for precise placement of the posterior working portal. | The surgeon should complete diagnostic arthroscopy from the posterior portal once established to assess for anterior pathology associated with glenohumeral instability. |
| A 70° arthroscope should be used for complete visualization of the posterior-inferior glenohumeral joint. | |
| The surgeon should maintain the cannula in the extracapsular space between the posterior capsule and muscle layer. | Both limbs of FiberWire must be within the cannula and cleared of all soft tissue before knot tying. |
| A spinal needle can be used percutaneously as a working instrument. | If multiple sutures are needed for capsular repair, the inferior-most suture should be tied first for better visualization of the remaining superior sutures. |
| Absorbable suture should be used to close the posterior portal. |
Footnotes
The authors report the following potential conflict of interest or source of funding: R.A.D. receives support from Allegheny Health Network (resident physician salary). J.J.C. receives support from International Society for Hip Arthroscopy, Arthrex, Breg, Allegheny Health Network, and Allegheny Singer Research Institute.
Supplementary Data
A technique for arthroscopic repair of a posterior glenohumeral capsular rupture with concomitant anterior and posterior labrum detachment is presented. Arthroscopic surgery is performed with the patient in the left lateral decubitus position with the right arm supported by an adjustable arm positioner. An anterior viewing portal is first established to identify the location and extent of the posterior capsule injury and precisely place the posterior working portal. The posterior capsule repair is performed by a side-to-side suture technique with the knots placed in the extracapsular layer between the capsule and rotator cuff muscle belly. The posterior and anterior labrum is also repaired with suture anchors. The posterior portal is closed with an absorbable suture in a side-to-side manner.
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Associated Data
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Supplementary Materials
A technique for arthroscopic repair of a posterior glenohumeral capsular rupture with concomitant anterior and posterior labrum detachment is presented. Arthroscopic surgery is performed with the patient in the left lateral decubitus position with the right arm supported by an adjustable arm positioner. An anterior viewing portal is first established to identify the location and extent of the posterior capsule injury and precisely place the posterior working portal. The posterior capsule repair is performed by a side-to-side suture technique with the knots placed in the extracapsular layer between the capsule and rotator cuff muscle belly. The posterior and anterior labrum is also repaired with suture anchors. The posterior portal is closed with an absorbable suture in a side-to-side manner.