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VPT1-00595-EN | A | Posterior Instability Repair

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Posterior Instability Repair

So. Pathologies. Pathologic theories of posterior instability. There are many retroversion, chondrolabral, retroversion, humeral retroversion, Hill-Sachs lesions, capsular attenuation, muscular imbalances, and throwers is very common too, but usually in my mind is a combination of the above that gets them into trouble. So what we did is we did a meta analysis of the world literature, Jeff DeLong and I, and we found out that in arthroscopy, there's almost 700 shoulders in athletes out of 739. And of that group, we looked at what how many we published for other things. So this is kind of what I learned. So almost well, actually 50%, 58% of the athletic shoulders that were published in the world literature actually came from our group. So I just want to tell you what we kind of learned from from that. So the first thing I can tell you is because I always give things in tens, if you've noticed. So the first thing I can tell you is that the etiology and the overhand athlete of posterior Postural instability is frequently different than contact athletes. So Jim Toboni and I, in 93, when everybody else was studying anterior, we wanted to go posterior. And we found out that chronic overuse microtrauma to the posterior capsule, capsular attenuation and posterior subluxation was very common. And then and we looked at in certain sports and we found that football players actually had a high rate of posterior instability. And Lee Kaplan and I looked at the combine data from the NFL. And we found that surely that offensive linemen were the greatest, followed by defensive linemen much more than any other positions. There's a second group of throwers, and throwers are completely different groups. So if you take care of throwers, they're completely different than the rest of our athletes. And what they do is they initially get a tight posterior inferior capsule. They get repetitive microtrauma after ball release, and then they get this progressive tearing of the posterior inferior labrum, and then they get mechanical symptoms or pain during follow through. But instability is not one of the symptoms. And there's a third group that's going to come out that's all about muscular imbalances with a tight packs and overactive lats. So there are some. The second thing I can tell we learned is physical exam findings predict a poor result for posterior instability. Is this circumduction test where the arm is out the back and then reduces? If you see that I haven't gotten very many people better once that once they show you that test, the next one is when you have a load and shift in neutral and you have them on the table and they just pop right out the back like that. I really haven't had much success at all by fixing that or by helping them with physical therapy. I think the oh, you want to be aware of hypermobility states. Last year alone, I diagnosed six people with Ehlers-Danlos syndrome. So you're going to treat those much differently than you would treat the treat your normal athletes. The next thing is be aware of bone loss. And the question is how much bone loss is too much. Now we kind of know anteriorly 25% or so, but posteriorly we really don't know because I mean, how much is too much? 25% is only 7.25mm. So what we did was there's no clear answer from biomechanical data or clinical data in the literature at all. So we looked at our 200 posterior repairs that we did and decreased bony width was predictive of a poor result, but it had nothing to do with a number of how much glenoid loss was. So it was a narrower glenoid. It had a higher risk of failure, but not a specific number. And we're trying to look at that. J.t. Tokich and Matt prevention were going on. We're looking at it right now. And then the question is what about Retroversion. Well how much is too much? Well, I can tell you that by the literature. Before we did the study, there was nobody that had anything to say about Retroversion afterwards. And of our 200 patients, once you fix the fix them retroversion did not make a difference. It had no clinical outcome once you fix them. Arthroscopically. So we looked at these again with Craig Morrow, and we wrote a paper on it and looking at our MRIs and the final result, there was no significant differences in scores for version, either bony version, retro version, or ChondralDrill version, and the only thing that was a predictor of poor results was decreased with the glenoid. The question then came to mind is I'm saying, well, there's got to be a number. It's 13%, 12%, 20%. We looked at ours and we found that there was no correlation between bone loss and poor results. Once you once you fixed them. So what we're going to do now is take preventers and kicks and my patients all together and use it one specific technique for bone loss. And see if we can give you a number the next time around. I will tell you that Brett Owens did a great study on risk factors for posterior instability in young athletes. And the most significant risk factor in active young athletes is an increased retroversion. So for every one degree of increased retroversion over the normal, there's a 17% risk of subsequent posterior instability. So it looks like pre-op. It makes a difference post-op. It didn't make a difference in our study. Ben has taught us beware of scapular dyskinesias in these people, because a lot of times they're going to present with scapular dyskinesias or winging of the winging the scapular, but all they're doing is protecting their their shoulder from going out the back. So you literally have to it gets scary, but you literally have to fix the posterior instability for the for the scapular dyskinesias to go away. In throwers protraction is very, very common. So you got to accept protraction that they're going to be protracted, especially in pitchers. But what happens is, is they get a tight pec in the front and their lats just overpower the back and pull. The capsule can't restrain it and it just pulls them out the back. So be careful when you do your physical exam to look particularly at a tightness in their PEC major and minor. The third thing I can tell you is that labral tears and retroversion, both bony and condor labor are common. They're not rare, as the literature says. So we've done we did multiple studies about labor lesions. And the first 100 patients we published, 57% of them had some sort of labral lesion. The fourth thing we learned is that posterior pathology is rarely isolated. It comes in combinations with slaps, slabs, partial cuff tears, reverse Hagel lesions, posterior glenoid and linebackers. So of our four over 400 patients on our current prospective study that we've operated on, over 40% of those had some additional pathology that needed to be addressed at surgery, whether it be a sleep aid or a partial cuff tear. Beware of of posterior avulsions. Okay. So reverse lesions, if you look pre-op on the MRI, you can see this large reverse Hagel lesion. And you have to preoperatively prepare a little differently for him than some others. And here's some concomitant lesions that we saw once from baseball a prior thermal and football. So you've got to be prepared for these capsular rents as you go along. The fifth thing I can tell you is that overhand athletes have poorer results and outcomes and return to sport. So if you look at the overall literature, when we looked at it, there were small numbers. They were not well documented and most of them did not fare well if you were an overhead athlete. And then so we looked at ours. So we thought we were a little better. We weren't we? If we looked at our first 27 throwers and published it, and we found out that 55% of our throwers were less likely to return to their preoperative sport. And when we looked at the 200 and we said, okay, in the 200, there were 56 overhand athletes. And the important thing we found out is that if you had a suture anchor repair, you had a 70% chance of going back. If you had an anchor less repair in a thrower, you only had a 22% chance of going back. So then we looked at a case match. So we got finally got enough people in our study that we could, we could case match two sets of people of throwers versus the whole group. And we took 48 of them throwing athletes and 48 non throwing athletes. They were perfectly matched groups. And we found out that throwers 85% returned to the sport and non throwers 87%. Not too bad right. What is bad because only 60% returned to the same level in throwers, and only 70% returned the same level in the whole group. And we're talking about the exact same level of playing now. Not not just playing. So then what about pitchers? Pitchers actually had better aces, pain score, stability, functional scores and were in general were better results than the whole throwing cohort that we looked at those against. But the outcomes were worse. 50% of the pitchers returned to sport versus 85% of the entire cohort. But 33% of the nine that returned returned at a lower performance, and 17% didn't return at all. So pitchers are one of the hardest ones to control for posterior instability. What I will tell you what I learned in the end. In the end, in throwers, to loose is always better than too tight and overhead. In athletes in contact athletes, they have better outcomes and better return to sport. We look at our 200 and we had 117 contact athletes. 93% of those went back, so they're a much better group. We looked at them and published on them of arthroscopic stabilization of posterior instability and is successful in American football players. We had a 93% return to sport and 79%, which is a good number for me, returned to sport at the same level, and a lot of these were college and professional athletes. So in the end, in contact athletes tight is always better than too loose in those because actually the offensive linemen like it because they can hold a little better because they don't have as much external rotation. So what about arthroscopic versus open? I can tell you this that arthroscopic treatment is better than open, especially in overhead throwers. Why do you do arthroscopic stabilization? Because you can return because you can do concomitant pathology. So partial cuff tears, slap eight lesions, capsule rents and haggles in the literature. Overall, it has lower recurrence rates and improved perioperative morbidity. So how do I do it. There's two ways I do it. That's what it kind of looks like in the back when you get there. I don't think we spent enough time abrading and taking care of the posterior labrum to kind of upset it. This is a cutaneous technique called the hot, what you also call a hybrid. We call it a zone specific. So we'll put a two for. Anchor in the bottom one because you can get a better Line to the glenoid. We use this real pass. If you haven't used real pass, it's really the angle is really good. It's a really small thing. They have it out there. It's called real pass. It's got about I don't know, ten yards of material in it. You can use. You can, you only need one. And then you just flip it around. And I use a sliding Weston. Not a little small not locking sliding locking not. And you can see the very small little portal we use. And then for the rest of the repairs I'm a big LabralTape fan. Labraltape is 39% stronger than that. Suture has a 37% greater pullout strength from the labrum, and that's where they usually fail. So LabralTape has really changed the way I do it, and I'm faster with it. So I would put one one on the bottom with the two four anchor, and then I'll have three labral tapes going up the back, and that usually will fix it. But you can see the the nice contour that you can get. Don't worry about the bumper. The bumper goes away. Everybody worries about the bumper. I always close the posterior portal because it's a stress riser. In the early revisions that I did, I would go in there and I'd look and I'd say, what's that big hole doing there? It just never filled in filled in correctly, so I always will close that with some PDFs. Now the other thing you can do is this is you can use a cannula, a lower cannula called a low profile cannula. And you can see it down there really low. There's another cannula and it's about three centimeters away from the axillary nerve. I did the dissections. So in small people I use a hybrid. And my big athletes typically I use the this technique here where I'll use LabralTape the whole way through. You want to get the the anterior or you want to get the posterior band of the anterior glenohumeral ligament. You want to get the anterior portion of it first, and then you get the posterior portion. And you can see that it reforms itself very well. And the problem with these athletes is they want to go too fast. You got to slow them down. The procedures you can do with arthroscopically are many. But what I would tell you is this don't do thermals with it. Don Lozano and I did the study back in, I don't know, it was 19, 2004, and we had a 40% failure rate when we used any type of thermal. So don't do that. We looked at our 2005 prospective study of 100. We had 91% good, excellent results. 86 returned to sport. Then we went to 200. And in the 200, it was quite clear to us, even from the 100, that the suture anchor group had a significantly better Aces score and had significantly better return to sport than the non suture group. So the literature summary of open versus arthroscopic arthroscopic wins in every way. So you really should think about doing that at recurrent instability. Ability to address concomitant pathology perioperative morbidity return to sport and cause diseases. Number eight the rotator interval rarely needs to be closed. It's just like in multidirectional. I still don't close it very rarely. So our first hundred athletes I did seven rotator interval closures. I probably those patients were really the MDIs which you saw before. I was just learning. The second 200 patients I did none. And they did have had a better result. And then Matt Preventer bailed me out and said, look, that he won the Air Cast award for this. In a study with the addition of a rotator interval closure after arthroscopic repair of anterior and posterior shoulder instability. And he said in the study that won the award, this study calls into question the need for an arthroscopic rotator or arthroscopic rotator interval closure in the setting of posterior instability. And I'll tell you, you don't need to do it. The ninth thing I learned is, when in doubt, use suture anchors. And the reason is that in all of our studies, overhand athletes, football players contact the anchor group had a significantly better ace score at the end that had a significantly better return to sport in every paper we did. The 10th thing is, I'm going to tell you is you're only as good as your physical therapist because they see him as a movie picture. You see him in snapshots. So get get your therapist out there that are good at taking care of these and make you look better. So indications for surgery, a failed rehab greater than six months, a large labor or flap tear on the MRI that you know is not going to get better. Posterior glenoid bone loss of greater than five millimeters. In my mind, I start thinking they're going to. That's what I've been using about 15% right now, but I don't know if that's the right number. That's just all Gestalt reverse haggles are or posterior capsule rents you have to address. They're not going to get better. So once you see them, you're going to have to fix them. And you're and the inability to return to sport at the same level. So the questions I'm commonly asked is when to anchor. I almost anchor all the time now. I use anchors all the time. When and how much to placate depends on the sport. Football aggressively throwers rarely when to debris. If you have a large flap tear with a stable rim, sometimes in throwers you can just debris the flap and you don't need to do anything. The hardest question is when to fix the labrum and release the posterior inferior capsule. That's about an hour long lecture, but when I have a labral junction tear, excuse me, and a significant internal rotation deficit, I will fix the labrum and then just cut the posterior band right above it, about five millimeters off it, and throwers to get their internal rotation and when to close the rotator interval. Really only in true MDIs if you need to. And I have really never done an interval closure in a thrower with a posterior capsule lesion.

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