ArticlePDF Available

Arthroscopic Posterior Bone Block Augmentation in Posterior Shoulder Instability

Authors:
  • Swedish Orthopedic Institute

Abstract and Figures

Background: Posterior instability is a relatively rare and challenging condition to treat. Soft-tissue procedures do not always provide satisfactory results. We present the results after arthroscopic posterior bone block augmentation with an iliac crest bone graft and a minimum of 12 months' follow-up. Materials and methods: Between 2008 and 2009, we performed 19 arthroscopic posterior bone blocks on 18 patients with posterior instability (bilaterally in 1 patient). The mean age was 29.85 years at the time of surgery. The mean follow-up was 20.5 months. All patients had a painful, unstable shoulder. Preoperative etiology included trauma, glenoid dysplasia, Ehlers-Danlos syndrome, and arthrosis with posterior glenoid erosion. Results: The Rowe score improved from 18.4 points to 82.1 points, and the Walch-Duplay score improved from 37.4 points to 82.9 points, both statistically significant (P < .01). Radiologic bone healing was achieved in all cases. Nine cases had an excellent result with return to the previous level of sports, six were satisfied, and three had a persistently painful shoulder. Subsequent removal of screws improved symptoms in two of these patients, and in one patient, a cause for the pain and persistent instability was not found. Conclusion: Arthroscopic posterior bone block augmentation presents a reliable technique for the treatment of symptomatic posterior instability with varying origin. Although this is a technically demanding procedure, in our experience, the potential benefits and minimally invasive nature outweigh the risks and benefits of more invasive procedures.
Content may be subject to copyright.
Arthroscopic posterior bone block augmentation
in posterior shoulder instability
Daniel Grant Schwartz, MD
a,
*, Sven Goebel, MD, FRACS
b
,
Kalman Piper, MBBS, FRACS(Orth)
c
, Bartlomiej Kordasiewicz, MD
a
,
Simon Boyle, MSc, FRCS(Tr&Orth)
d
, Laurent Lafosse, MD
a
a
Alps Surgery Institute, Clinique G
en
erale, Annecy, France
b
Perth Shoulder Clinic, Claremont, Australia
c
Australian School of Advanced Medicine, Sydney, Australia
d
York Teaching Hospital, York, UK
Background: Posterior instability is a relatively rare and challenging condition to treat. Soft-tissue proce-
dures do not always provide satisfactory results. We present the results after arthroscopic posterior bone
block augmentation with an iliac crest bone graft and a minimum of 12 months’ follow-up.
Materials and methods: Between 2008 and 2009, we performed 19 arthroscopic posterior bone blocks on
18 patients with posterior instability (bilaterally in 1 patient). The mean age was 29.85 years at the time of
surgery. The mean follow-up was 20.5 months. All patients had a painful, unstable shoulder. Preoperative
etiology included trauma, glenoid dysplasia, Ehlers-Danlos syndrome, and arthrosis with posterior glenoid
erosion.
Results: The Rowe score improved from 18.4 points to 82.1 points, and the Walch-Duplay score improved
from 37.4 points to 82.9 points, both statistically significant (P<.01). Radiologic bone healing was
achieved in all cases. Nine cases had an excellent result with return to the previous level of sports, six
were satisfied, and three had a persistently painful shoulder. Subsequent removal of screws improved symp-
toms in two of these patients, and in one patient, a cause for the pain and persistent instability was not
found.
Conclusion: Arthroscopic posterior bone block augmentation presents a reliable technique for the treat-
ment of symptomatic posterior instability with varying origin. Although this is a technically demanding
procedure, in our experience, the potential benefits and minimally invasive nature outweigh the risks
and benefits of more invasive procedures.
Level of evidence: Level IV, Case Series, Treatment Study.
Ó2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Posterior glenohumeral instability; shoulder; Bankart; Latarjet; arthroscopic reconstruction;
glenoid; bone loss
Treatment for posterior glenohumeral instability, which
may account for up to 5% of shoulder instabilities,
8
was
first proposed in 1938 by F
evre and Mialaret.
6
Techniques
for bone augmentation did not appear until suggested by
No IRB approval was required for this study.
*Reprint requests: Daniel Grant Schwartz, MD, Alps Surgery Institute,
Clinique G
en
erale d’Annecy, 4 Chemin de la Tour la Reine, F-74000
Annecy, France.
E-mail address: daniel.g.schwartz@gmail.com (D.G. Schwartz).
J Shoulder Elbow Surg (2012) -, 1-10
www.elsevier.com/locate/ymse
1058-2746/$ - see front matter Ó2012 Journal of Shoulder and Elbow Surgery Board of Trustees.
http://dx.doi.org/10.1016/j.jse.2012.09.011
Hindenach
11
in 1947. Fried
7
and Jones
13
reported on
5 cases and 1 case, respectively, with posterior instability
where bony augmentation was performed. Later, in 1952,
McLaughlin
23
proposed a combination of a bone block and
capsular plication.
22
Currently, this has evolved to some
authors recommending a bone block harvested from the
scapular spine
1,28
or either an open technique
29
or an
arthroscopic technique through the rotator interval.
3
Sirveaux et al
30
described the use of an iliac crest bone
graft in 9 cases or a pedicled acromial bone block in 9 cases
originally described by Kouvalchouk et al.
15
In this tech-
nique a pedicled acromial bone block including a portion of
the deltoid muscle is rotated to the posterior glenoid. Sir-
veaux et al claim that this technique not only has
a mechanical advantage but also acts like a dynamic sling
similar to the principle of the Latarjet procedure.
Regardless of the procedure, posterior glenohumeral
instability can be managed effectively nonoperatively;
however, in cases when intervention is required, soft tis-
sue–based and bone-based procedures have been proposed.
Traditional current surgical options include open or arthro-
scopic soft-tissue stabilization or bone-based procedures
using open posterior bone block augmentation with iliac
crest,
29
a pedicled acromial deltoid flap,
15
glenoid osteoto-
mies,
10
or even an arthroscopic bone block based through the
rotator interval.
3
Controversy exists within the literature
regarding optimal treatment, and because of its low incidence,
no consensus has been reached. We present a new arthroscopic
technique of arthroscopic posterior bone block augmentation,
which was found to be both reproducible and effective.
Materials and methods
Between 2008 and 2009, the senior author (L.L.) performed 19
arthroscopic posterior bone blocks on 18 patients with posterior
instability (bilaterally in 1 patient). There were 13 male patients
and 5 female patients. The mean age was 29.85 years (range,
15-56 years) at the time of surgery. The dominant shoulder was
the affected shoulder in 8 cases. The mean follow-up was 20.5
months. All patients complained of a painful and/or unstable
shoulder. In 1 patient, the instability was related to Ehlers-Danlos
syndrome.
In 12 patients, the onset of posterior instability was traumatic
in origin, and 4 patients (5 shoulders) had glenoid abnormalities:
glenoid dysplasia in 2 patients (3 shoulders), glenoid retroversion
in 1 patient, and glenoid arthrosis with posterior bone loss in
1 patient. In 2 patients, under arthroscopic bone block stabiliza-
tion, no definable cause for the instability was found despite
failure of a long course of nonoperative management. The mean
time between trauma and surgery was 6 years (range, 2-35 years).
In 9 patients, at least 1 true dislocation had occurred, whereas in
the remaining patients, persistent subluxation and/or pain was the
reason for intervention. Five patients had prior arthroscopic
surgery: four had a posterior Bankart repair (two of which were
arthroscopic revisions of a previous arthroscopic posterior labral
repair), and one had anterior arthroscopic stabilization. Every
patient tested positively for instability with the posterior drawer
test, posterior jerk test, and O’Brien test. The preoperative range
of motion in the glenohumeral joint was normal in all patients. All
patients underwent arthroscopic posterior bone block augmenta-
tion by the senior author (L.L.) using bone graft harvested from
the ipsilateral iliac crest.
Statistical analysis with a paired Student ttest with the level of
significance defined as P<.05 was performed on functional
results.
Surgical indications
Posterior instability can be either traumatic or atraumatic.
Traumatic posterior dislocations result from combined
internal rotation and adduction, which commonly occur
from a fall or more classically with seizure activity or
electrocution. In general, vigilance is required to not miss
posterior dislocations. Clinical findings may include
a history of a painful shoulder with or without a history of
dislocation, a positive O’Brien test,
24
a positive posterior
jerk test, and radiologic features consistent with a bony
defect (either a reverse Hill-Sachs lesion or posterior gle-
noid bone loss). All patients were assessed with standard
radiographs (fluoroscopically controlled anteroposterior
radiograph in internal, external, and neutral rotation and
lateral radiograph with a Bernageau view) and either
a computed tomography scan with or without contrast or
magnetic resonance imaging.
Atraumatic posterior shoulder dislocation can be asso-
ciated with hyperlaxity, multidirectional instability, or
glenoid dysplasia.
9
Often, the dislocation is voluntary or
readily reproducible by the patientdwith or without pain.
Caution must be used when dealing with some of these
patients, especially with voluntary and intentional dis-
locators, in whom treatment modalities may have poor
results. These patients may be difficult to distinguish from
involuntary but unintentional dislocators who may be
merely able to reproduce their instability.
A trial of nonoperative treatment with physical therapy
is warranted for posterior instability.
20
If nonoperative
therapy fails, surgical intervention is indicated. At our
institution, a simple soft-tissue repair is indicated only in
cases of an isolated episode of traumatic posterior instability,
a radiologically identified labral lesion, and no posterior
glenoid bone loss. Patients presenting with recurrent post-
traumatic posterior dislocation and bone defects (either
humeral or glenoid sided despite the size), as well as unin-
tentional dislocators with glenoid dysplasia or hyperlaxity,
were indicated for an arthroscopic posterior bone block.
Arthroscopic posterior bone block technique
Patients are anesthetized with combined general anesthesia
and an interscalene regional block. Local anesthetic is also
used to infiltrate the region of the bone graft harvest site at
the iliac crest. The patients are set up in the beach-chair
position with approximately 45of inclination of the back-
rest, to allow adequate access to the bone graft harvest site.
2 D.G. Schwartz et al.
During the procedure, as well as after the bone graft has been
harvested, the backrest is inclined further to approximately
70. The procedure is performed using the same equipment
used for the arthroscopic Latarjet procedure
16
and can be
divided into a number of steps, as described herein.
Step 1: arthroscopic joint evaluation
A thorough joint evaluation is always performed before
harvesting of the bone graft, to confirm the clinical diag-
nosis and indication for bone block. The arthroscope is
introduced through the standard posterior ‘‘A’ portal, and
a standard diagnostic arthroscopy is performed; however,
for reverse Hill-Sachs lesions and posterior labral lesions,
this portal is not practical. An anterior ‘‘E’’ portal is
established through the rotator interval, and the arthroscope
is shifted to this portal to accurately manage the evaluation
of the posterior glenoid rim, labrum, capsular lesions, and
reverse Hill-Sachs lesion. The soft tissue can be palpated
with a probe introduced through the ‘‘A’ portal.
Step 2: bone graft harvest and preparation
Once the indication is confirmed, the graft is harvested from
the anterior iliac crest. An incision 5 cm posterior to the
anterior iliac spine of the crest, just inferior (distal) to the
crest, is used in the approach to avoid scars directly on the
crest. The surgeon harvests the bicortical graft, using the
lateral and anterior cortex but retaining the inner table of the
pelvic bone with the K-wire guide from the arthroscopic
Latarjet equipment, which creates 2 parallel K-wires into the
iliac crest (Fig. 1). Two 3.2-mm holes are drilled with
the cannulated drill and tapped, and then, 2 ‘‘top hat’
washers are inserted (Fig. 2). The graft is harvested with an
oscillating saw or osteotome. Care must be taken not to
create a fracture into one of the drill holes of the graft. The
final size of the graft is 2 cm 1cm1 cm, with the pre-
drilled holes centered on one side. After the graft has been
removed, it is attached to the double-barreled cannula with
the use of 2 long cannulated screws, creating a single unit
that can be manipulated easily into its final position (Fig. 3).
Step 3: glenoid preparation
The arthroscope is introduced into the glenohumeral joint
from the anterior ‘‘E’’ portal, to allow good visualization of
the posterior structures. Instruments are introduced through
both the ‘‘A’ portal and a trans-infraspinatus poster-
osuperior ‘‘B’’ portal (Fig. 4). If a labral lesion is present, it
is mobilized from the posterior glenoid neck in the same
fashion as a Bankart repair. If there is no labral lesion, the
labrum is left intact and a capsulotomy is performed to
expose the posterior glenoid neck. The muscle fibers of the
infraspinatus and teres minor are exposed, and then the
posterior glenoid neck is abraded with the bur until
bleeding bone is exposed with a flat surface.
Step 4: graft positioning and fixation
Next, the posterior ‘‘A’ portal is enlarged (by approxi-
mately 2-3 cm) to allow passage of the graft and double-
barreled cannula with a blunt trocar (Fig. 5). The scalpel is
Figure 1 K-wire fixation in the iliac crest using a bone block
guide in a right hip. The patient’s head is located at the top of the
photo, with the medial pelvis located to the right of the picture.
Figure 2 Top hat washers (TAG Medical, Cheshire, UK) are
inserted (A) before harvesting of the graft from the iliac crest (B).
Arthroscopic posterior bone block 3
also used to enlarge the muscle split and capsulotomy. The
graft is inserted through the posterior portal and then
moved through the muscle split and capsule until it is
positioned against the posterior glenoid neck and flush with
the glenoid articular surface along the posterior-inferior
surface of the neck (Fig. 6) with the cancellous portion of
the graft against the glenoid neck and cortical portion
directly posterior. The graft is then stabilized by inserting
two long 1.48-mm K-wires, through the guide, the graft and
into the glenoid (Fig. 7). Before insertion of the K-wires,
the double-barreled cannula is held parallel to the articular
surface. When inserting the wires, the surgeon should pay
special attention to not advance the K-wires completely
through the glenoid (no more than 40 mm) because they
may damage the anterior neurovascular structures.
Because of the perspective from the anterior portal with
the 30arthroscope, there is a natural tendency to tilt the
graft at an angle with the inferior surface being prominent
instead of being flush. It is important to check that
the physiological posterior drawer is still possible after
the graft placement. Once the surgeon is satisfied with the
position of the graft and both K-wires have been placed, the
glenoid is drilled and two 3.5-mm partially threaded screws
are inserted over the K-wires (Fig. 8). The inferior screw
should be inserted completely, before the superior screw is
drilled, to prevent shifting of the graft’s position. At this
stage, it is still possible to correct the level of the graft
according the glenoid by rotating it around the inferior
screw. The graft should never be proud. The screw should
not be more than 32 to 36 mm in length, and any length
greater than 40 mm warrants a check because this likely
means that the screw angle is too large relative to the gle-
noid surface with resulting malpositioning of the graft.
Once the 2 screws have been inserted and the K-wires
Figure 3 Graft attached to a handle (DePuy Mitek, Raynham,
MA, USA) to facilitate graft insertion and positioning during
arthroscopy.
Figure 4 Posterior capsule detachment through the ‘‘B’’ post-
erosuperior portal.
Figure 5 A blunt rectangle trocar is introduced through the ‘‘A’’
portal and inserted to create a channel for the graft.
Figure 6 Graft insertion into the joint through the infraspinatus
muscle (posterior portal).
4 D.G. Schwartz et al.
removed, the final position is checked and any prominent
parts of the graft can be trimmed with the bur (Fig. 9).
Step 5: soft-tissue repair
If needed, the posterior labrum and capsule are repaired to
the glenoid rim by use of 2 suture anchors, similar to the
standard Bankart repair technique (Fig. 10). The capsule is
not closed routinely.
Step 6: rehabilitation
Patients are immobilized in 20of abduction in neutral
rotation for 6 weeks. Passive shoulder, elbow, and hand
range-of-motion exercises begin the day after surgery;
however, exercises are to remain pain free, and any internal
rotation exercises should be excluded. Active range-of-
motion exercises begin at 3 weeks, with progression to
strengthening exercises at 6 weeks when a radiograph is
taken to confirm graft stability (Fig. 11).
Results
At a median follow-up of 20.5 months (range, 13-32
months), all patients were evaluated postoperatively.
Preoperative activity levels can be seen in Table I. Both
patients in the high-risk group returned to sport at the 3-
and 4-month time points. Two patients in the level 2 group
did not return to sport. The overall Rowe and Walch-
Duplay scores improved significantly from 18.4 points to
82.1 points (P<.01) and from 37.4 points to 82.9 points
(P<.01), respectively (Table II).
Radiologic union of the graft, as judged by postoperative
computed tomography scan, was achieved in all patients
(Fig. 12), although 1 patient required revision after
complete lysis of the bone graft. After revision, the patient
went on to achieve union. There were no significant
differences in flexion or internal rotation compared with the
contralateral extremity postoperatively; external rotation
decreased by a mean of 9compared with the contralateral
extremity postoperatively (P<.05).
Nine patients reported that they were very satisfied with
the procedure, seven patients were satisfied, and two
patients (three shoulders) were not satisfied. No patients
had any donor-site morbidity from the crest harvest. One
patient who remained dissatisfied had persistent insta-
bilitydwith no frank dislocationdwith pain (postoperative
visual analog scale [VAS] score of 7 of 10 compared with
5 of 10 preoperatively) and severe limitation of function.
Union of the graft was achieved, and no obvious cause for
the persistent instability was discovered. The patient’s
contralateral shoulder was revised (as discussed in the
‘‘Complications’’ section). In the other patient, revision
surgery was necessary because of a prominent iliac crest
bone graft that caused persistent pain with significant
Figure 8 Graft positioning with cannulated screws.
Figure 9 Graft final position after fixation.Figure 7 Temporary graft fixation with K-wires.
Arthroscopic posterior bone block 5
limitation of function. At the time of operation, an erosion
of the humeral head was found, caused by a prominent part
of the posterior bone graft. This created an erosion of the
humeral cartilage, and subsequently, after remodeling of
the graft with the bur, the patient’s symptoms improved.
The patient with pre-existing arthrosis and posterior erosion
of the glenoid reported persisting pain (VAS score of 2 of
10) albeit at levels significantly lower than before surgery
(VAS score of 6-7 of 10).
Complications
Six arthroscopic hardware removal reoperations with
concomitant procedures were performed. In 1 patient,
a K-wire broke during advancement through the glenoid
during the original procedure but was considered to be in
stable position (intra-glenoid) and therefore was left in
place. This K-wire later migrated anteriorly toward the
neurovascular bundle and required removal at the time of
screw removal. In 5 other patients, screw removal was
necessary because of pain and discomfort in the region of
the infraspinatus tendon. In 2 of these 5 cases, on the
postoperative radiograph, it was noted that the inferior
screw was malpositioned below the glenoid; however, the
patients were neurovascularly asymptomatic. In 1 of these
cases, it was necessary to remove the screws only, with no
additional procedures performed. There was partial lysis of
the lateral graft border noted in this patient. In 4 patients,
additional procedures were performed, comprising trim-
ming of the graft borders because of a proud glenoid rim;
partial osteolysis of the iliac crest bone graft was noted in
1 patient, and a loose fragment was removed.
In 2 shoulders (1 patient), an additional posterior capsu-
lorrhaphy was performed at the time of the index procedure
because a large capsulolabral lesion was present. In this
patient, who underwent sequential bilateral bone grafting,
the graft of the left shoulder was found to have completely
resorbed on imaging studies, and revision iliac crest bone
graft was performed 13 months after primary surgery.
Hardware was removed 8 months after revision. Therefore,
counting screw removals (6) and complete resorption
requiring revision (1), there were a total of 7 reoperations.
Discussion
Treatment for posterior shoulder instability is still
a controversial issue. Open bony stabilization appears to be
a reliable but difficult procedure. In this article, we describe
an option to treat patients with a less invasive approach. To
our knowledge, this is the first case series of arthroscopic
posterior bone block augmentation in posterior gleno-
humeral instability, as well as presentation of the trans-
infraspinatus arthroscopic technique. Our results in this
series are in line with previous reports of open posterior
bone block augmentation, which is encouraging. The
benefit of this technique is that concomitant joint patholo-
gies, which are relatively common, can be treated at the
same time with relatively little effort, and the general
benefits of having a much smaller wound and dissection are
appealing. This technique can be used for combined soft-
tissue and bony defects, as well as for revisions after
previous soft-tissue reconstructions.
In our series of 19 shoulders, we noted no postoperative
recurrence of dislocation or subluxation. Overall, our
results were satisfactory, with 16 of 19 shoulders having
good to excellent results after the index procedure; more-
over, after revision surgery, this number rose to 18 of 19.
Complications requiring reoperation including hardware
removal occurred in 7 of 19 shoulders. Complications from
our early experience (proud grafts or bothersome hardware)
were hard lessons that have significantly changed our
clinical practice but ultimately resulted in improved patient
care. Although lysis did seem to present in certain
patientsdespecially noticeable to a small degree in patients
after a ‘‘second arthroscopic look’dthis is likely related to
Wolff’s law, that is, the body will retain bone that is
physiologically loaded. Finally, a revision rate of 36.8% is
Figure 10 Posterior Bankart repair (A) after graft fixation with
final repair (B).
6 D.G. Schwartz et al.
quite high for a novel arthroscopic technique; however,
since our initial 19 cases (the senior author has performed
a total of 29 arthroscopic posterior bone block procedures
up to July 2012), our complication rate has steadily fallen,
with no increase in revision surgery.
Although our study is limited by short-term follow-up,
a diverse patient population (multiple etiologies as an indi-
cation for surgery), and bias from surgeon-collected range-
of-motion and outcome scores, we believe that this series
provides a unique addition to the literature. There have been
no scientific articles of arthroscopic posterior bone blocks
and their clinical outcomes. Our early results show that bone
block augmentation can effectively address posterior insta-
bility in an appropriately indicated patient. Obviously, our
complication rate was too high; however, we attribute this to
the learning curve associated with the procedure initially. An
additional problem within our series is the case of a patient
(bilateral shoulder posterior bone block with capsular
tightening) who went on to have a ‘‘dissatisfied’’ result;
therefore, surgeons should take caution when performing
a simultaneous soft-tissue procedure because this could have
been a contributing factor to the poor outcome. In addition,
patient selection should be stressed to the treating surgeon.
Patients with glenoid dysplasia fared poorly in our cohort;
Figure 11 Postoperative radiographs after arthroscopic posterior bone block: anteroposterior (A), scapular Y (B), and Bernageau (C)
views.
Table I Activity level: preoperative patient data
No. of
shoulders
Level 0: no sport 1
Level 1: risk-free activity (rowing, swimming breaststroke, cross-country skiing, sailing, and so on) 1
Level 2: activity with contact (martial arts, cycling, soccer, rugby, waterskiing, downhill skiing, horse riding, and so on) 13
Level 3: activity with cocking of arm (climbing, weight lifting, swimming overarm and butterfly, pole vaulting, canoeing,
golf, hockey, tennis, baseball, and so on)
2
Level 4: high-risk activity (basketball, handball, volleyball, kayaking, water polo, and so on) 2
Table II Walch-Duplay and Rowe scores subdivided by patient etiology
Etiology No. of patients/shoulders Walch-Duplay score Rowe score
Preoperatively Postoperatively Preoperatively Postoperatively
Trauma 12/12 39.1 87.9 20 88.3
Glenoid dysplasia 2/3 28.3 65 15 60
Ehlers-Danlos syndrome 1/1 40 85 15 80
Arthrosis 1/1 35 80 15 80
Unknown 2/2 40 80 17.5 80
Arthroscopic posterior bone block 7
however, low numbers of patients, as well as the complicated
clinical course of 1 patient, contributed significantly to this
observation. Furthermore, we may have been unable to
appropriately ‘‘classify’’ patients within the realms of trau-
matic, dysplastic, or idiopathic, which is why 2 patients
remained unclassified within our grouping. This lack of an
appropriate classification scheme for posterior instability has
been a topic of recent discussion within the literature, with
new efforts determined to provide surgeons with appropriate
means to classify these difficult-to-treat patients.
4
The literature itself has not proved that one bone block
technique is superior to another. Levigne et al
17-19
reported
a series of 26 shoulders with a mean 5-year follow-up
treated with an open posterior bone block technique with
the graft being harvested from the iliac crest. They suggested
examining the etiology of the instability (voluntary or
voluntary then involuntary or pure involuntary and so on) to
dictate treatment guidelines; however, little else has been
published since this initial report. Servien et al
29
presented
a study of 21 patients with recurrent posterior post-traumatic
instability treated with open posterior bone block, harvested
from iliac crest, with a mean follow-up of 6 years and good
clinical outcomes based on Duplay scores (85.6 points) and
Constant scores (93.3 points). Of the 20 patients, 11 (55%)
had no pain and 16 (80%) had normal and symmetric
external rotation. The authors concluded that the bone block
procedure could be a procedure of choice in recurrent
posterior dislocation, given the high presence of bony lesions
in these patients (93.75%). They proposed soft-tissue repair
for subluxations rather than recurrent dislocations. Although
we included patients with subluxation within our patient
population, we believe that our arthroscopic results are
similar to the results reported with open techniques.
Additional reports that mirror ours include that of
Barbier et al
2
; in 2009, they presented a report of 8 patients
with a mean follow-up of 3 years after posterior bone block
augmentation with iliac crest bone graft. Seven of these
eight cases were post-traumatic, and the sole nontraumatic
case was due to an epileptic seizure episode. All patients
had recurrent dislocations. Postoperatively, there was no
nonunion or recurrence. Only 4 patients were able to return
to their preoperative level of sports. All patients were found
to have normal range of motion in abduction and anterior
elevation, but in 3 patients, external rotation was limited by
a mean of 20. The mean postoperative Constant score was
96.25 points, and the mean Duplay score was 90 points.
Three patients required an additional procedure, two for
hardware removal and one for posterior deltoid repair. At
a mean of 3 years’ follow-up, the study of Barbier et al
showed satisfactory or better results in 80% of cases.
There is clearly a lack of consensus regarding surgical
treatment, because of a lack of understanding of the path-
omechanical issues leading to posterior instability. In many
cases, nonoperative treatment leads to a satisfactory
outcome for patients with posterior instability. The surgical
options for the treatment of posterior instability can be
divided into soft-tissue and bony procedures and further
divided into open or arthroscopic procedures. One of the
main problems after soft-tissue repairs is the recurrence of
instability due to stretching of the posterior capsule as the
normal range of motion and activity are restored. Early
reports of arthroscopic posterior stabilization with capsu-
lorrhaphy and sutures/anchors showed poor results, with
high recurrence rates up to 72%,
12
with a clear correlation
between glenoid retroversion and probability of repair
failure, and may be more of historical interest; however,
they underscore the limited understanding of posterior
instability within the literature.
18,19
Another technique
using a posterior staple for the capsulorrhaphy yielded
similarly unacceptably high failure rates.
32
Figure 12 Postoperative computed tomography scan with axial
(A) and coronal (B) cuts.
8 D.G. Schwartz et al.
More recent studies on soft-tissue stabilization have
shown results that are improved but still cannot be
considered as acceptable. McIntyre et al
21
reported a high
incidence of recurrence (23%) after an arthroscopic soft-
tissue stabilization at 2 years’ follow-up. More recent
publications have shown an improvement, with failure rates
of 3% to 12%.
1,25-27
Wolf and Eakin
35
presented promising
results of arthroscopic posterior capsule plication in 14
patients with 2 years’ follow-up. Of the patients, 12 had
excellent results and 2 had fair results. One recurrent
dislocation was reported, treated by revision arthroscopic
posterior capsule plication. Similarly, Williams et al
34
re-
ported good results in 27 patients with a mean follow-up of
5 years. Kim et al
14
reported the presence of an incomplete
lesion of the posteroinferior labrum, which they found
analogous to an anterior Bankart lesion and often coexist-
ing with posterior capsule stretching. After arthroscopic
labral repair and posterior capsular shift, they presented 27
cases with good results at a mean of 3 years’ follow-up.
Provencher et al
25
reported a study of 33 patients with
a recurrence rate of 12% (4 patients) and persistent pain in
9% (3 patients) after arthroscopic repair. Savoie et al
27
presented the results of arthroscopic treatment in 131
patients with multiple intra-articular lesions; a good
outcome was found in 97% at a mean follow-up of
28 months.
Most pathologies can be treated with arthroscopic soft-
tissue procedures, but subsequent stretching of the capsule
remains an important problem. This is an important
distinction as to why the senior author prefers a bone-based
procedure in patients with repetitive luxation or subluxa-
tion. Other authors also advocate bony procedures in
posterior shoulder instability to avoid problems with
capsular stretching. These include humeral rotation
osteotomy, glenoid osteotomy, and the aforementioned
posterior bone block. Humeral rotation osteotomy has not
been widely used because it carries a relatively high risk of
complications.
31
Glenoid osteotomy remains a solution in
cases of glenoid dysplasia and retroversion over 15.
33
This
procedure is also fraught with a relatively high risk of
complications. English and Macnab
5
pointed out that there
is a tendency for humeral head anterior subluxation to
occur, and Gerber et al
8
showed that the humeral head
could migrate anteriorly and impinge on the coracoid
process. This procedure should be reserved for ‘‘special’
cases because of the high risk of intraoperative complica-
tions such as intra-articular fracture or loss of correction
related to anterior cortex fracture or graft extrusion.
10
Conclusion
Although arthroscopic posterior bone block stabilization
remains a technically demanding procedure and longer
follow-up is required to validate the efficacy of this
procedure, we have found the complication rate to
decrease as our experience has improved. Furthermore,
the procedure is efficacious and reproducible.
Disclaimer
Laurent Lafosse owns patents with TAG Medical related
to the development of the surgical instrumentation used
in this study. All the other authors, their immediate
families, and any research foundations with which they
are affiliated have not received any financial payments
or other benefits from any commercial entity related to
the subject of this article.
References
1. Arciero RA, Mazzocca A. Posterior acromial bone block augmenta-
tion for the treatment of posterior glenoid bone loss associated with
recurrent posterior shoulder instability. Tech Shoulder Elbow Surg
2006;7:210-7. http://dx.doi.org/10.1097/01.bte.0000235403.44352.6e
2. Barbier O, Ollat D, Marchaland JP, Versier G. Iliac bone-block auto-
graft for posterior shoulder instability. Orthop Traumatol Surg Res
2009;95:100-7. http://dx.doi.org/10.1016/j.otsr.2008.09.008
3. Barth J, Grosclaude S, L
adermann A. Arthroscopic posterior bone
graft for posterior instability: the transrotator interval sparing cuff
technique. Tech Shoulder Elbow Surg 2011;12:67-71. http://dx.doi.
org/10.1097/BTE.0b013e31822bd5e9
4. Boileau P, Hardy MB, Schwartz DG. Recurrent posterior shoulder
instability revisited. In: Boileau P, editor. Shoulder concepts 2012:
arthroscopy, arthroplasty, & fractures. Paris: Sauramps Medical; 2012.
p. 255-8.
5. English E, Macnab I. Recurrent posterior dislocation of the shoulder.
Can J Surg 1974;17:147-51.
6. F
evre M, Mialaret J. Indications et technique des but
ees r
etro-gl
eno
ıdi-
ennes dans les luxations post
erieures de l’
epaule. J Chir 1938;52:156-67.
7. Fried A. Habitual posterior dislocation of the shoulder-joint; a report
on five operated cases. Acta Orthop Scand 1948;18:329-45.
8. Gerber C, Ganz R, Vinh TS. Glenoplasty for recurrent posterior shoulder
instability. An anatomic reappraisal. Clin Orthop Relat Res 1987:70-9.
9. Gerber C, Nyffeler RW. Classification of glenohumeral joint insta-
bility. Clin Orthop Relat Res 2002:65-76. http://dx.doi.org/10.1097/
00003086-200207000-00009
10. Hawkins RH. Glenoid osteotomy for recurrent posterior subluxation of
the shoulder: assessment by computed axial tomography. J Shoulder
Elbow Surg 1996;5:393-400.
11. Hindenach JC. Recurrent posterior dislocation of the shoulder. J Bone
Joint Surg Am 1947;29:582-6.
12. Hurley JA, Anderson TE, Dear W, Andrish JT, Bergfeld JA,
Weiker GG. Posterior shoulder instability. Surgical versus conserva-
tive results with evaluation of glenoid version. Am J Sports Med 1992;
20:396-400.
13. Jones V. Recurrent posterior dislocation of the shoulder; report of a case
treated by posterior bone block. J Bone Joint Surg Br 1958;40:203-7.
14. Kim SH, Ha KI, Park JH, Kim YM, Lee YS, Lee JY, et al. Arthro-
scopic posterior labral repair and capsular shift for traumatic unidi-
rectional recurrent posterior subluxation of the shoulder. J Bone Joint
Surg Am 2003;85:1479-87.
15. Kouvalchouk JF, Coudert X, Watin Augouard L, Da Silva Rosa R,
Paszkowski A. Treatment of posterior instability of the shoulder joint
Arthroscopic posterior bone block 9
using an acromial stop with a pediculated deltoid flap [in French]. Rev
Chir Orthop Reparatrice Appar Mot 1993;79:661-5.
16. Lafosse L, Boyle S. Arthroscopic Latarjet procedure. J Shoulder
Elbow Surg 2010;19:2-12. http://dx.doi.org/10.1016/j.jse.2009.12.010
17. Levigne C, Dejour D, Mangione P, Walch G. Posterior instability of
the shoulder. J Shoulder Elbow Surg 1996;5:S35.
18. Levigne C, Garret J, Walch G. Posterior bone block for posterior
instability. Tech Shoulder Elbow Surg 2005;6:26-35.
19. Levigne C, Mangione P, Walch G. Recurrent posterior shoulder
subluxations and dislocations with traumatic onsetdabout 31 cases
with surgical treatment [abstract]. J Shoulder Elbow Surg 1999;8:508.
20. Matsen FA III, Lippitt SB, Bertlesen A, Rockwood CA Jr, Wirth MA.
Glenohumeral instability. In: Rockwood CA, Matsen FA, Wirth MA,
Lippitt SB, editors. The shoulder. Philadelphia: Saunders Elsevier;
2009. p. 617-770.
21. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic treatment
of posterior shoulder instability: two-year results of a multiple suture
technique. Arthroscopy 1997;13:426-32.
22. McLaughlin HL. Follow-up notes on articles previously published in
the journal. Posterior dislocation of the shoulder. J Bone Joint Surg
Am 1962;44:1477.
23. McLaughlin HL. Posterior dislocation of the shoulder. J Bone Joint
Surg Am 1952;24:584-90.
24. O’Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. The active
compression test: a new and effective test for diagnosing labral tears
and acromioclavicular joint abnormality. Am J Sports Med 1998;26:
610-3.
25. Provencher MT, King S, Solomon DJ, Bell SJ, Mologne TS. Recurrent
posterior shoulder instability: diagnosis and management. Oper Tech
Sports Med 2005;13:196-205. http://dx.doi.org/10.1053/j.otsm.2006.
01.004
26. Provencher MT, LeClere LE, King S, McDonald LS, Frank RM,
Mologne TS, et al. Posterior instability of the shoulder: diagnosis
and management. Am J Sports Med 2011;39:874-86. http://dx.doi.org/
10.1177/0363546510384232
27. Savoie FH III, Holt MS, Field LD, Ramsey JR. Arthroscopic manage-
ment of posterior instability: evolution of technique and results.
Arthroscopy 2008;24:389-96. http://dx.doi.org/10.1016/j.arthro.2007.
11.004
28. Scapinelli R. Posterior addition acromioplasty in the treatment of
recurrent posterior instability of the shoulder. J Shoulder Elbow Surg
2006;15:424-31. http://dx.doi.org/10.1016/j.jse.2005.10.012
29. Servien E, Walch G, Cortes ZE, Edwards TB, O’Connor DP. Posterior
bone block procedure for posterior shoulder instability. Knee
Surg Sports Traumatol Arthrosc 2007;15:1130-6. http://dx.doi.org/10.
1007/s00167-007-0316-x
30. Sirveaux F, Leroux J, Roche O, Gosselin O, De Gasperi M, Mole D.
Surgical treatment of posterior instability of the shoulder joint using
an iliac bone block or an acromial pediculated bone block: outcome in
eighteen patients [in French]. Rev Chir Orthop Reparatrice Appar Mot
2004;90:411-9.
31. Surin V, Blader S, Markhede G, Sundholm K. Rotational osteotomy of
the humerus for posterior instability of the shoulder. J Bone Joint Surg
Am 1990;72:181-6.
32. Tibone JE, Bradley JP. The treatment of posterior subluxation in
athletes. Clin Orthop Relat Res 1993:124-7.
33. Walch G, Ascani C, Boulahia A, Nove-Josserand L, Edwards TB.
Static posterior subluxation of the humeral head: an unrecognized
entity responsible for glenohumeral osteoarthritis in the young adult.
J Shoulder Elbow Surg 2002;11:309-14. http://dx.doi.org/10.1067/
mse.2002.124547
34. Williams R Jr, Strickland S, Cohen M, Altchek DW, Warren RF.
Arthroscopic repair for traumatic posterior shoulder instability. Am
J Sports Med 2003;31:203-9.
35. Wolf EM, Eakin CL. Arthroscopic capsular plication for posterior
shoulder instability. Arthroscopy 1998;14:153-63.
10 D.G. Schwartz et al.
... Positive outcomes from treatment using bone block augmentation via an arthroscopic approach are reported by Daniel Grant Schwartz et al. in their publication on managing posterior shoulder instability in patients with hEDS and multidirectional instability (MDI). 18 The publication describes the implantation of a posterior bone block with an iliac crest bone graft in a patient diagnosed with hEDS and MDI. 18 The effectiveness of this method is evidenced by the authors' follow-up conducted 12 months post-surgery. ...
... 18 The publication describes the implantation of a posterior bone block with an iliac crest bone graft in a patient diagnosed with hEDS and MDI. 18 The effectiveness of this method is evidenced by the authors' follow-up conducted 12 months post-surgery. Improvements were noted in the Walch-Duplay Score, indicating the degree of shoulder instability, which increased from 40 to 85, and in the Rowe Score assessing shoulder stability, motion, and function, which rose from 15 to 80, indicating a favorable evaluation. ...
... Improvements were noted in the Walch-Duplay Score, indicating the degree of shoulder instability, which increased from 40 to 85, and in the Rowe Score assessing shoulder stability, motion, and function, which rose from 15 to 80, indicating a favorable evaluation. 18 Although the iliac crest bone graft technique is typically performed using an open approach, attempts have also been made to carry out this procedure arthroscopically, as demonstrated by the aforementioned authors. ...
Article
Full-text available
Introduction Ehlers-Danlos Syndrome (EDS) is a group of connective tissue disorders, the essence of which are abnormalities in the function of collagen. One type of EDS with an unknown genetic basis is the hypermobile form of EDS (hEDS). hEDS manifests mainly in musculoskeletal defects, as well as chronic pain. There is extremely high need to correctly diagnose and then correctly treat patients with hEDS. Initially conservative treatment is used, but if patients fail to achieve relief, surgical treatment is considered. Aim of the study The purpose of the authors was to gather all the information regarding hEDS in terms of surgical treatment. The authors focused mainly on finding the advantages and disadvantages of the various methods and also on collecting information on the indications for choosing the given surgical methods. Materials and methods The methodology of the literature search involved using the keywords: „hypermobile Ehlers-Danlos syndrome”, „shoulder instability”, „joint hypermobility”, „chronic pain” and „Latarjet”. The search terms were entered into the PubMed database. References include systematic reviews, but also clinical trials, as well as case reports. Conclusion Currently available literature does not offer enough information to undertake standardized management of patients with hEDS. Not only is there a lack of studies on groups of patients with hEDS, but also on large groups of patients without hEDS, making it impossible to choose the best method based on the available clinical trials. Moreover, through the lack of such studies, it becomes impossible to truly assess whether patients with hEDS have a higher rate of surgical failure and thus a higher risk of inappropriate management of a specific patient with hEDS.
... return to their previous level of sport, three having persistent pain, and two having revisions.34 The Mclaughlin and Modified Mclaughlin procedures, similar to the Remplissage, are also options with indications that include a chronic locked posterior dislocation of less than 6 months THE ARCHIVES OF BONE AND JOINT SURGERY. ...
Article
Full-text available
Posterior shoulder instability (PSI) is a shoulder pathology that is challenging to diagnose, leading to treatment delay and exacerbation of symptoms. Etiology can be both traumatic and atraumatic, and a comprehensive clinical history plays a significant role in achieving diagnosis. Imaging in the setting of PSI can reveal a reverse-Bankart lesion, a reverse Hill-Sachs lesion, posterior labral cysts, and potentially glenoid or lesser tuberosity fractures. Both conservative and surgical options exist for patients with PSI, and management often depends on case severity, extent of bone loss, and patient goals and expectations. Holistic patient education regarding the etiologies, mechanisms and possible treatment options available is pivotal for achieving high levels of patient satisfaction and optimal outcomes.
... Several studies have found that bone block surgery for posterior shoulder instability can lead to good clinical outcomes and improved PROs. However, Schwartz et al. found a high rate of revision surgery needed (39), and Clavert et al. reported a pain likely due to recurrent instability rate of 12% (40). Both studies reported a While the most common graft options include iliac crest autograft and DTA, it is critical to understand the benefits and pitfalls of each type of reconstruction, as both have been shown to convey similar biomechanical contact pressure and strength profiles in cadaveric models (32). ...
Article
Full-text available
Posterior shoulder instability is an increasingly recognized phenomenon and comprises approximately 5% of all shoulder instability cases. Posterior shoulder instability presents a complex clinical challenge, particularly when associated with bone loss. Bone loss may be present in up to 25% of patients with posterior shoulder instability. Understanding its etiology, diagnosis, and treatment options is crucial for optimal patient outcomes. Young athletic individuals, especially football linemen and throwing athletes, are commonly affected, with symptoms ranging from insidious onset pain to noticeable changes in athletic performance. History, physical examination, and imaging, including radiographs and advanced three-dimensional imaging, play pivotal roles in diagnosis, with specific tests like the Jerk, Kim, and load and shift tests aiding in provocation. Posterior glenoid bone loss (pGBL), whether dysplastic, attritional, or acute, significantly impacts management decisions. When pGBL exceeds critical thresholds, soft tissue repair alone may be insufficient, necessitating glenoid reconstruction with bone block procedures. Both iliac crest autograft and distal tibial allograft (DTA) offer viable options, with considerations including donor site morbidity and graft integration. Surgical techniques for reverse Hill-Sachs lesions vary from subscapularis transfers to arthroscopic balloon osteoplasty, each aiming to restore native anatomy and prevent engagement. Bipolar bone loss, involving both glenoid and humeral head defects, presents additional challenges and may require combined soft tissue and bony procedures. Quantifying bone loss and understanding its implications are essential for surgical planning. While various techniques show promise, further research is needed to elucidate their long-term outcomes and refine treatment algorithms for posterior shoulder instability with bone loss.
... Posterior glenoid reconstruction with a free bone graft can also be performed arthroscopically. Schwartz et al. [35] reported on a series of 19 shoulders with overall positive results, including radiologic bone healing in all cases. However, the authors emphasized a steep learning curve and the technically demanding nature of the procedure. ...
Article
Full-text available
Posterior glenoid bone loss (pGBL) is frequently associated with posterior shoulder instability. Posterior glenohumeral instability accounts for a small percentage of shoulder pathologies, and critical bone loss in posterior instability has not been well defined in the literature. Younger patient populations who participate in activities that repetitively stress the posterior stabilizing structures of the shoulder are more prone to developing posterior shoulder instability. A variety of surgical options have been described, ranging from isolated capsulolabral repair to glenoid osteotomy. Soft-tissue repair alone may be an inadequate treatment in cases of pGBL and places patients at a high risk of recurrence. Our preferred technique for posterior glenoid reconstruction in cases of pGBL involves the transfer of a free iliac crest bone graft onto the native glenoid. The graft is contoured to fit the osseous defect and secured to provide an extension of the glenoid track. In this study, we review pGBL in the setting of posterior instability and describe our technique in detail. Further long-term studies are needed to refine the indications for glenoid bone graft procedures and quantify what constitutes a critical pGBL.
Article
» Suture button fixation has emerged as an effective surgical construct in arthroscopic and open Latarjet and anterior glenoid reconstruction with free autograft bone with high rates of bone block healing. » Biomechanical data suggest that screw and suture button mechanical fixation constructs provide similar load to failure and stability for the Latarjet procedure. » Preliminary bone healing models have identified that flexible fixation may exhibit a higher degree of bone callus maturation, whereas rigid fixation results in excessive callus hyperplasia » Mechanical tensioner use provides consistent tensioning of suture button constructs and improves bone-to-bone healing rates when used for anterior glenoid reconstruction surgery. » Evidence is lacking regarding the reliability of bone-to-bone healing of allografts to native bone with use of suture button constructs. » Suture button fixation provides good short- and mid-term clinical outcomes for the arthroscopic Latarjet and anterior glenoid reconstruction with free autograft bone.
Chapter
Posterior shoulder instability (PSI) has become an increasingly common condition, occurring in around 20% of surgically treated shoulder instability cases and most commonly in young, male athletes participating in contact or overhead sports. Patients commonly present with multiple nonspecific symptomologies and frequently do not describe specific instability, making it difficult for clinicians to make an accurate differential diagnosis. Nonoperative management is successful in some cases. However, advancements in arthroscopic and open surgical techniques have provided good outcomes in patients who fail conservative treatment when indicated. A comprehensive understanding of the pathophysiology, the relevant clinical and diagnostic modalities, and the concomitant conditions associated with PSI is vital to provide optimal results to patients. This chapter will aim to provide current concepts on the diagnosis and management of PSI, reviewing surgical indications as well as describing modern techniques and associated complications.
Article
Background: The purpose of this study was to evaluated results of arthroscopic treatment of the traumatic recurrent unidirectional posterior subluxation. Materials and Methods: We treated twenty-seven patients who had traumatic recurrent unidirectional posterior subluxation of the shoulder by arthroscopic labral repair and posterior capsular shift and prospectively evaluated for a mean of thirty-nine months (range,24 to 85 months). Patients who had posteroinferior instability, multidirectional instability, atraumatic onset, or revision cases were excluded. There were twenty-five male and two female patients with the mean age of twenty-one years (range, 14 to 33 years). All patients were involved in sports activity. All had a significant traumatic event prior to the onset of the instability. Stability, motion, three objective measurement (UCLA, ASES, and Rowe scores) and two subjective measurements (pain and function visual analogue scale) were evaluated. Results: The most common finding in magnetic resonance image-arthrogram was separation of the posteroinferior labrum without displacement in 9 patients, In arthroscopic examination, all patients had one or more lesions in the posterior inferior labrum and capsule. The most common finding was incomplete stripping of the posterior inferior labrum (18 patients). The posteroinferior capsule subjectively appeared to be stretched in twenty-two patients. At follow-up, all patients had improved shoulder function and scores(p
Article
Posterior shoulder instability is a relatively rare condition and surgical challenge. Arthroscopic techniques have allowed for improved diagnosis and management of this condition. The purposes of this report are to outline the problem of posterior shoulder instability, review the biomechanics and relevant pathoanatomy, and describe our preferred surgical technique. Our results of arthroscopic treatment of posterior instability will also be discussed and pearls for operative success highlighted.
Article
The prevalence of posterior glenohumeral instability has been estimated to occur in up to 5% of all patients who present with shoulder instability. However, there has been a heightened awareness of this disorder with improvements in physical examination, imaging, and the use of arthroscopy. Posterior shoulder instability has been attributed to primarily capsular redundancy, laxity, and posterior labral pathology and detachment. Infrequently, in cases with involuntary and/or traumatic causes, posterior glenoid bone loss, or retroversion has also been implicated as a cause for failure of treatment, either nonoperatively or operatively. Although the associated posterior glenoid bone loss is an infrequent pathoanatomical feature in patients who present with posterior shoulder instability, this can lead to surgical failure if not addressed. Several different procedures have been described to deal with bone loss from humeral head defects or posterior glenoid deficiency. These have included glenoid osteotomy, humeral rotational osteotomy, and bone grafting of the posterior glenoid. This article will describe a technique where posterior glenoid bone loss is treated with extra articular augmentation of autogenous bone graft harvested from the spine of the acromion.
Article
Posterior bone block is one of the surgical procedures proposed in the literature for posterior instability of the shoulder. Prognosis is better in traumatic than in atraumatic instability. Voluntary subluxations with true intentional episodes are a contraindication for surgery. To have an accurate and reproducible technique, we recommend 7 surgical steps: (1) Vertical deltoid approach, (2) Horizontal infraspinatus splitting approach, (3) Medial T-shaped arthrotomy, (4) Joint exploration and treatment of labral lesions, (5) Abrasion of posterior glenoid cortex, (6) Harvesting and preparation of an accurately sized and shaped iliac graft, and (7) Cautious fixation of the graft with 2 low compression screws. Association with capsulorrhaphy and/or glenoid osteotomy may be necessary, respectively, in cases of hyperlaxity and/or excessive glenoid retroversion. The best treatment of patients who have recurrent posterior instability of the shoulder remains controversial. Precise, specific, and durable rehabilitation prior to surgical treatment has been universally recommended.1-7 If this program fails to relieve the patient's symptoms, a great variety of surgical procedures have been proposed: soft-tissue procedures (posterior capsulorrhaphy, reverse Putti-Platt, biceps tendon transfer), osteotomy of the glenoid, rotational osteotomy of the humerus, and posterior bone block. Various combinations of these procedures have also been proposed. Posterior bone block is not the most popular procedure that has been recommended in this pathology but it is our preferred method, alone or in combination with posterior capsulorrhaphy and/or glenoid osteotomy.
Article
Posterior glenoid augmentation with a bone graft is sometimes required in the management of posterior shoulder instability. We describe a new arthroscopic technique that consists of passing the graft through an anatomic portal: the rotator interval. This approach diminishes the damage on posterior structures. We believe that this less invasive approach might allow earlier motion recovery and reduce the complications related to an extensive or blind posterior approach. Clinical relevance: New technique relevant to arthroscopic management of posterior glenohumeral instability.