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arthroscopic posterior labrum repair


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Right shoulder posterior glenohumeral joint instability and posterior labrum tear.

POSTOPERATIVE DIAGNOSIS: Right shoulder posterior glenohumeral joint instability and posterior labrum tear.

PROCEDURE: Right shoulder examination under anesthesia, diagnostic arthroscopy, arthroscopic extensive debridement, and arthroscopic posterior labrum repair.

Examination under anesthesia revealed 2+ posterior drawer and trace positive inferior sulcus. Diagnostic arthroscopy revealed no significant glenohumeral articular defects. There was a posterior labrum tear. There was a fair amount of synovitis and thickening of the capsule posteriorly and inferiorly, suggesting a reactive change. There was no subscapularis or rotator cuff tear and no superior labrum tear. The biceps looked stable. There did appear to be a small dimpling, suggesting a reverse Hill-Sachs impaction injury. There were no other obvious anomalous findings. The shoulder appeared to be just a little bit more tight arthroscopically than one would anticipate based on his exam.

INDICATIONS: The patient is a 23-year-old gentleman who injured his shoulder in a work-related injury, working as a firefighter. He had onset of posterior instability. He knew all about this, having undergone to stabilize his opposite shoulder roughly 6 years ago following a football injury. MRI confirmed a posterior labrum tear, which correlated with his clinical findings of positive jerk test and positive posterior drawer. We needed to get Worker's Compensation authorization and, once this was granted, we went ahead with the surgery. He understood the potential risks and benefits of the surgery, having been through a similar surgery on the opposite side. He gave written informed consent and was scheduled on an elective basis after appropriate preoperative medical clearance.

DESCRIPTION OF PROCEDURE: On the day of the procedure, the patient was brought back to the operating room and placed supine on the operating table. General anesthesia was established. Preoperative antibiotics and interscalene block were placed in the holding area. Under anesthesia, an examination was carried out with the findings noted above. The patient was then positioned in the lateral decubitus position with the operative right side up. All pressure points were padded, including placement of an axillary roll. The patient's right shoulder and arm were prepped and draped in standard manner for arthroscopic shoulder stabilization in the lateral decubitus position. We used 15 pounds of balanced suspension. We used an Arthrex STaR sleeve for abduction positioning during critical portions of the procedure. We began diagnostic arthroscopy and the arthroscope was introduced through a straight posterior portal into the glenohumeral joint and systematic diagnostic arthroscopy ensued with the findings noted above. We established a low anterior portal just above the subscapularis. We inserted the arthroscopic shaver across a metal cannula. We did a limited debridement and then used the switching stick technique to bring the arthroscope anteriorly and view the posterior structures. A plastic 7-mm cannula was placed posteriorly. We also established an accessory posterolateral portal. This had slightly better trajectory and access to the glenohumeral joint. We then used the shaver through the portals to debride the posterior labrum. There were a couple of flap tears, and these were removed. We lightly freshened up the synovium as well. We then used our percutaneous kit to establish a portal for anchor placement. This was a little bit more lateral and had better trajectory for the tear. It extended from 6:00 to 8:00. We placed an anchor at the 6:00 position. This was done by inserting the anchor over the percutaneously-placed guide. We used a 2.4-mm BioComposite SutureTak. The anchor had very good fixation. This was loaded with a single #2 FiberWire suture. Through the plastic cannula, we used the Linvatec Spectrum with the left 45-degree attachment to penetrate the capsule labral tissue, exiting right where the anchor had been placed. We passed a #1 PDS suture through the Spectrum and retrieved that, along with one limb of the suture from the anchor. We used a relay technique. This allowed us to relay the #2 FiberWire suture from the anchor in retrograde fashion back out through the capsule labral tissue. Both ends of the sutures were retrieved out the plastic cannula and standard arthroscopic knot-tying techniques were carried out. We repeated the process identically with the second anchor, placed at the 7:00 position. Then a third anchor was placed right at the edge of the glenoid at the 8:00 position. This time, however, we used an angled BirdBeak to directly retrieve the suture. The BirdBeak penetrated the capsule labral tissue where the 8:00 anchor had been placed and retrieved directly one limb of the #2 FiberWire suture from the anchor. Both ends of the suture were then tied arthroscopically out the cannula posterolaterally to complete the repair. We used a three-suture anchor, three suture repair. We had very nice reconstitution of the capsule-labral complex. The humeral head centered itself nicely on the glenoid. There was some very minor scuffing of the superficial cartilage on the glenoid side, and this was lightly debrided with the shaver. We copiously irrigated the glenohumeral joint and withdrew all arthroscopic instruments. We closed the arthroscopic portals, including the posterior, posterolateral, and percutaneous portals, as well as the anterior portal. Steri-Strips and sterile compressive dressings were applied. The arm was placed in a padded soft brace. The patient was repositioned in the supine position for this and promptly awakened from anesthesia, having tolerated the procedure well, and was taken from the operating room to the recovery room in satisfactory condition. The plan is for the patient to be discharged on oral analgesics with instructions to begin outpatient physical therapy and follow up in the office in one week.