I would like to thank Anna for this opportunity. My name is Daniel Song, and I'm an orthopedic surgeon at Evans Army Community Hospital in Colorado Springs. My task is to talk about the posterior bank heart. I will concentrate this talk on the surgical technique. My only disclosure is that I was assigned this title, and not all of these are easy for me. This is an outline of what I will be covering in this talk. There are similarities between posterior and anterior instability, but many more differences. Posterior instability is much more common than we previously thought, and it is important to be able to identify these patients accurately in clinic. Surgical treatment for posterior instability can be challenging because of the tight spaces, but with the proper preparation and being comfortable with many surgical techniques, we can help patients achieve good outcomes. Accurate diagnosis always starts with a good history. Things that are important from history include age, handedness, history of trauma, position, and treatment so far. The first thing to know about posterior labral tears is that they are much more common than we previously thought. Although anterior instability is still more common, posterior labral tears can make up to 25% of all shoulder instability surgeries in one consecutive series. Classically, posterior instability has been associated with significant trauma, electrocution, or seizures, but the majority of patients with posterior instability do not endorse a specific injury. Unlike anterior labral tears where the chief complaint is typically instability, the chief complaint for most posterior labral tears is pain. This pain occurs with resistance activities while the shoulder is in flexion and internal rotation. Patients can also complain of decreased athletic performance, loss of strength, or inability to perform the same amount of push-ups or bench press as much weight as before. It is very important to have a high index suspicion for posterior instability in the young active population. A full physical examination of bilateral shoulders should be conducted. There are many described physical examination tests for the evaluation of posterior labral tears. My favorite is the push-pull test. In this test, you have the patient supine with the shoulder off the table. You pull up on the wrist while putting a posterior director force on the humerus. Two important things to mention about the physical exam is, number one, a positive posterior labral test should recreate the patient's symptoms. And number two, you should be wary of the 20 to 30-year-old with bursitis-type findings on physical examination. Most 20 to 30-year-olds do not have significant rotator cuff pathology, and the bursitis can be secondary to micro-instability from anterior and or posterior labral tears. In these patients, you can inject glycocaine into the subocriminal space and re-examine for posterior labral tears. Imaging should start with x-rays. An MRI or MRA can be very helpful in identifying posterior labral tears. CT scans can be helpful to identify glenoid abnormalities such as bone loss or retroversion. Nonoperative management starts with activity modification, physical therapy, and anti-inflammatory medications. Success of nonoperative management has been reported in the literature and varies depending on the study. This study had a 52% success rate of nonoperative management. These are the risk factors identified in this study for failure of nonoperative management. When nonoperative management fails and the patient is indicated for operative fixation of the posterior labral tear, the first-line surgery is generally an arthroscopic posterior labral repair. Successful surgery starts prior to getting to the operating room. Dr. Ahmad was one of my fellowship mentors, and he wrote this book entitled Skill, one of the chapters discussed preparing for an operation. Preparing for an operation can be scrubbing similar cases with mentors or colleagues. It can also come from participating in a lab or an anechores. You can also prepare by thinking about a surgery step-by-step in your mind, making mental notes of all the things that can go wrong and what steps you can take to fix them. This is something I do before every surgery. The goal is that I've either seen or thought about how a case can go wrong and what I want to do about it. If something bad happens in the OR and it is the first time you've experienced it or thought about what to do about it, this can be extremely stressful. In the food world, mise en place refers to the setup required before cooking where all the ingredients are prepped and organized in a way that allows efficiency. In the OR, the same preparation should be done with your equipment and implants. Having everything you need in an accessible manner can maximize efficiency and minimize frustrations. Having multiple backup plans is also extremely important. This should be part of your OR preparation. I've done posterior labral repairs in both the beach chair and lateral decubitus positions and I strongly prefer the lateral decubitus position. The distraction and access to the posterior and inferior glenoid in my hands is significantly better in this position. There are other talks about this topic so I won't go into great details, but I do a standard lateral decubitus position with an axillary roll and add a 6-tile bump in the axilla to help with lateral distraction. Like all orthoscopic surgeries, portal placement is critical and I will make as many portals as necessary to perform a safe surgery. Typically I use a posterior portal that is more lateral than the standard posterior portal. There is a commonly described posterior lateral or accessory posterior portal that is 3-4 centimeters off the posterior lateral chromium. What I have found is with my more lateral posterior portal and curved guides, I can typically get to the inferior and posterior glenoid. I will not hesitate to create the posterior lateral or accessory posterior portal if my standard posterior portal will not get me the trajectory to safely place anchors. My anterior portals are typically anterior inferior and anterior superior. I typically use 3 cannulas for these cases and will often use a self-retaining type cannula. Maintaining cannulas is important especially for these posterior labral tears as it is easy for them to come out of the joint. I try to be vigilant and hold the cannulas as instruments are inserted and taken out of the shoulder. If a cannula comes out, I try to avoid forcing them back in but rather place a switching stick followed by a dilator and then reinsert the cannula in a very controlled manner. I do a standard diagnostic arthroscopy initially from the posterior portal. I then transition my camera to the anterior superior portal to really better evaluate the posterior labrum. Preparation of the glenoid is important to allow healing of the posterior labrum. With the arthroscope and the anterior superior cannula, I first use what I call the more angled tissue elevator slash liberator from the anterior inferior cannula to start preparing the posterior glenoid. Care must be taken when advancing this from the front to the back. I then use various rasps and shavers to prevent the glenoid to aid in the healing of the posterior labral tear. It is often difficult to perform good glenoid preparation from the posterior portal so I will often create the portal Wilmington. This provides a better angle to prepare the posterior glenoid. I believe the angle of approach for anchor placement is the most important step in making these posterior labral repairs feel quote unquote easy. Typically with the more lateral posterior portal and curved drill guides, I am able to place anchors safely but I will not hesitate to create the posterior lateral portal if needed. There are many different types of anchors and techniques to perform this surgery. While most have their go-to technique, it is important to have that second and third backups for different scenarios. My preference has now become all suture knotless tensionable suture anchors. I like this technique because even in a tight shoulder I can place anchors and pass sutures safely. My first backup plan is a single loaded all suture anchor that I can pass and tie in a mattress fashion. I like this technique because I can still use a curved guide in a tight space. I like to tie mattress sutures to avoid having the knot migrate to the glenoid. Less often I will pass the suture through the posterior labrum, thread them into an anchor and then place the anchor into the glenoid. If using this technique you have to be extremely mindful of your angle of approach. With this technique you initially drill with a very stiff drill guide where you can lever the humeral head out of the way. The final anchor inserting device is less stiff so if the angle is not the same as the initial drill the suture anchors can easily break. After completing the posterior labrum repair I typically close the posterior portal. I use an anti-grade passer, grab the suture from the anterior infra portal and then use the anti-grade passer again from a different spot to retrieve the suture. Post-operatively I am likely slower than most. I have not had a problem with long term post-operative stiffness and in my population a slower rehab does not usually impact their career. In conclusion, posterior labral tears are more common than previously thought. A high level of suspicion is critical when evaluating young patients with atraumatic shoulder pain. Preparation prior to getting to the operating room, being mindful of your angle of approach and being comfortable and ready to utilize different surgical techniques is key to a successful outcome for these patients. Thank you.

posterior bankart tears

shoulder instability

diagnosis

surgical technique

rehabilitation process