Name: Revision Posterior Labral Instability: Knotted to Knotless
Uploaded: 2017-10-05T00:00:00Z
Channel: Arthrex

<p>Matthew Provencher, MD, (Vail, CO) describes his migration from knotted to knotless labral fixation techniques while describing a case where his patient required a revision posterior labral repair. Dr. Provencher discusses both his knotted index procedure and his knotless revision repair while sharing several pearls regarding the unique challenges of posterior instability in a highly active patient.</p>

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VPT1-00778-EN | A | Revision Posterior Labral Instability: Knotted to Knotless

Matthew T. Provencher

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Revision Posterior Labral Instability: Knotted to Knotless

I'm here today to present a case of a 22 year old male who was military special forces and was trying out for a professional American football team. He presented the clinic with a chief complaint of deep, vague shoulder pain, but also the inability to use the shoulder the way he used to. He had an MRI arthrogram, which demonstrated a posterior labral tear, as demonstrated here by the white arrow, and the dotted arrow showed a patulous capsule. So he was brought to surgery, where he underwent an arthroscopic stabilization. Here you see some typical findings in posterior instability. The cannula is in the front and the arthroscope is from the posterior. And what you can see here are some labral flaps tears. And then the posterior tear component from approximately 6:00 to 10:00 posteriorly. It's important to prepare the labrum adequately and get a good bleeding interface between the glenoid labrum. We use a combination of elevators and also shavers and bone cutting shavers to get a good bleeding response. The posterior lateral portal is critical to the success of this procedure. It's a percutaneous portal approximately four centimeters directly lateral to the posterior lateral aspect of the acromion. I bring a spinal needle in needle in. And here you can see the trajectory, which is really nice, which gets us to the bottom of the shoulder. The important area to address is the 6 to 8:00 position in posterior stability. So we want to put that first anchor right at the 6:00 position, which is the extent of the tear anteriorly. We bring in the 3.0mm fish mouth with the sharp trocar. This facilitates percutaneous passage high up against the humerus. And here we can see it penetrating through the capsule. And then we place it right at the 6:00 position. I gently tap this down with a mallet to make sure that the fish mouth does not migrate. And then we put a 3.0mm double loaded SutureTak at this 6:00 position. We then use a combination of hooks to do a repair. And this one I'm going to do a horizontal repair as well as a vertical repair, because I think this is a very important area of instability posteriorly that we have to address. Here you can see the final anchor construct. There's the 6:00 anchor, which is a combination of vertical and horizontal through the double loaded. And then we have three additional anchors up to the 10:00 position demonstrating reconstitution of the labrum and capsule repair. Well what happened he did well for about one and a half years, but he had a recurrent injury at football training camp. He was doing very well, was able to get back to all of his lifting and had excellent function. No loss of motion and really good scapular control. However, he did have a recurrence of symptoms after he took a hit while he was blocking a teammate during a drill. And this position of flexion and internal rotation with the arm out the back is the classic posterior instability type of injury that he sustained. Again, the Mr. ArthroRome was obtained. He had a recurrent labrum tear, maybe a little bit larger capsule, but there was no capsular tears off the humerus and no other injuries. A CT scan I always obtain, especially in revision settings, because I want to make sure that there was no bone loss and he had no erosion posteriorly at all of his of his glenoid, meaning that it was really just a soft tissue injury. So he was taken to surgery where he had a revision. Arthroscopic posterior stabilization. The arthroscope here is from posteriorly. We're bringing in the probe to assess what happened. And what you can see is his prior implants, the SutureTak with the FiberWire. They're well aligned and they're almost spot welded. And this is very typical after FiberWire SutureTak repair. However, you can see that he tore in several areas and his capsule was patulous in the back, although there were no capsular tears off the humerus and no rents, so removed his implants and utilized this device, which is part of the Arthrex elevator set. It's a steep elevator set. From the time of his initial surgery to this surgery, the elevator set was released, and you can see how nicely this elevator now is able to prepare the posterior labrum from 6:00 to 10:00, and to breed the bone and all the scar tissue on the bone so that we get a very good, nice healing response. I used a peak PushLock and what had also been released in the time from his original surgery to the revision surgery was LabralTape, and I really like this and have basically switched over now to a full knotless technology since this has been released for all of my labral repairs, this demonstrates the final repair. There are four peak PushLock anchors and LabralTape demonstrate a very good solid knotless construction. I was very happy with this repair, very happy with the final construct. And you can see my evolution of technology from a knotted construct to a knotless fixation. Well, how did he do? His final outcome was that he was able to get back to three years as a tight end in professional football, and still continues to this day as military special forces. Thank you.

Revision Posterior Labral Instability: Knotted to Knotless

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Revision Posterior Labral Instability: Knotted to Knotless

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