Thanks, everybody. So this talk is about posterior instability, getting to the back. These are my disclosures. As we all know, posterior instability has become increasingly recognized particularly when we speak to our military colleagues we know that their symptoms of instability pain and dysfunction, and the principles of course for repair are not that dissimilar but what we utilize with answer instability. The question of course is, how do we get to the back. And when you get to the back, how do you do the repair. So we have here a 19 year old male left also right hand dominant left shoulder. He fell while snowboarding three years ago, he has pain with instability, he's never required a physician assisted reduction. Here's his physical examination as you can see has a full range of motion good strength has a positive jerk, and he has positive positional posterior instability. You can see on his x rays there's nothing too unremarkable per se. And then on his MRI you can see he does have a posterior labrum tear here on multiple cuts capsule looks pretty good. Glennon contour it looks pretty good as well, at least on this MRI. Although we know that that may not be in fact the best test for this. So, what do I like to do. I like to really place positions in the lateral decubitus position I think it has significant advantages, particularly related to circumferential access to the shoulder. I like to turn the bed away from the anesthesiologist so that I can stand at the head of the bed, and also my assistant can therefore apply a transitional loads and surely our posterity, so that I can get to the areas that I need to get to for portal placement of course you can make a standard posterior portal but I do like a twin anterior portal approach with the standard enter inferior portal, but they're really the key portal here is the anterior superior lateral portal. This is created just about two centimeters off the anterior lateral quarter of the equipment, you can see here how it is, and to the super sponsor posterior to the biceps tendon. So as you can see here, we're looking from now. First, a posterior portal. We create an anterior lateral portal and this is the view can get you can see our posterior labrum here and how that's a much better view and then of course a posterior portal. Of course you can look for a reveals reverse Hillside lesion as well. So when I do this type of procedure. I like to view, particularly from the anterior lateral portal, which gives me a nice top down view of the glenoid. How do we release it. So usually you can release the posterior labrum for the anterior portal so I'm looking for an anterior superior lateral portal and bringing instruments to an anterior portal or you can reverse things by also looking to an anterior portal, but bringing instruments to an anterior superior lateral portal, as we are doing here. Either way you can use both approaches to release the posterior labrum. Once you get there of course the key to putting the anchors in is using a separate portal because the standard posterior portal is actually quite parallel to the face of the glenoid so you really what you want to do is create this posterior lateral poster inferior portal, and it gives you a 45 degree angle of approach to the face of the glenoid. So you can see it here that's the posterior inferior portal or the posterior lateral portal, I would create that 45 degree angle of approach to the posterior glenoid so you can put your anchors in. As far as the anchor and searching is concerned of course there's many different types of anchors you can use if you use a guide it's really good because you can kind of lever the head forward to give you a better angle of approach that, of course, is usually but also we can use all suture anchors or knotless anchors as well. There are many different types of options but remember as well that you can have a knotless options which can sometimes valuable. We can see here again getting to low down portal at the seven o'clock or six o'clock position. Suture passage. There are many different types of way to pass sutures, I generally find a hook type instrument is extremely valuable. However, you can also use antiquated suture passing devices, as well as such as a scorpion or an elite pass or something like that. Once you are going to pass the sutures of course you can make different types of suture configurations a simple suture of course it's the easiest thing to do. Other times you if you think there was a significant amount of capsule actually you can do a pinch tuck technique as you can see here, would you grab a bit of a pinch of a capsule and then go in around the labrum as well and this creates a full of tissue to essentially repair the labrum but also tighten the capsule as well. And I think that when I only have pain I generally do a labrum strict labrum repair, but if I have a patient who has significant capsular laxity, and in particular involuntary positional instability, those patients are generally going to get a pinch tuck technique as well. Essentially after that you want to do your final repair, you can see here you can tie your sutures. In this case we've done an oblique vertical mattress suture you can see the type of repair you can get with a free edge there immediately. Other times you get a very subtle lesion here you can see a Kim type lesion. In this particular case you have to releasing on almost like create a larger lesion before you do the repair. This takes a case, I've only done simple sutures. And then this last particular case, it's another poster labrum repair. We've done essentially knotless sutures, using a racking stitch type of configuration. All those are of course acceptable techniques. Capsular tears can occur as well post your haggle lesions or reverse haggle lesions has been described by a number of authors, unlike a standard haggle lesion these are actually easier to repair because you don't have to deal with a subscapularis and it's not as many neuromassive structures, which are concerning. We also have combined reverse bankrupt lesions with reverse haggle lesions as you can see here, this patient has a capsular tear as well. In this particular case we're going to repair the labrum, and then later repair the capsule. And when you repair these types of lesions, not to over constrain one of the repairs that is you don't want to grab too much capsule on the labrum repair and then be unable to repair your capsule laterally, and vice versa. Sometimes I'll in fact do both repairs but not tie them until the very end to ensure that we can get as much both sides repaired together and completely balanced per se. So in conclusion, posterior instability is being increasingly identified and because of that there's going to be more and more surgery that you will see come to your clinic. The key to me is really the angle of approach. I like to use the Angiospermial lateral portal for viewing, and as well using a posterior inferior or posterior lateral portal for my anchor insertion. Thank you very much.

posterior instability

surgical repair process

lateral decubitus position

labrum and capsule repair

suture anchor options