AANA Lab Course 906- Técnicas Avanzadas de Cirugía de Hombro-La parte difícil del manguito: Una visita guiada para la reparación perfecta de las roturas del subscapular-Fernando Barclay, MD

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This document provides a comprehensive overview of posterior shoulder instability (PSI), authored by Dr. Fernando Barclay. PSI is a less common form compared to anterior instability, accounting for about 4% of cases, often related to trauma, seizures, or microtrauma (e.g., military personnel). It can present in multiple forms including inveterate locked, unidirectional, multidirectional, and posterior lesions as an extension of anterior instability.<br /><br />Etiology varies by sport type: in throwing athletes, microtrauma and postero-inferior contracture (GIRD) lead to labrum injury and pain without frank instability, where surgical techniques favor looser repairs but results are modest. Contact athletes often sustain direct trauma causing true instability with capsulolabral and bony lesions, where tighter surgical repair yields better outcomes.<br /><br />Diagnostics rely on clinical tests like the Jerk and Push-Pull tests, MRI (with contrast), and 3D CT scans to assess bone and soft tissue involvement, though correlation between imaging and symptoms is about 62%. Important prognostic factors include scapular dyskinesia, hyperlaxity, bony defects (degree of glenoid retroversion and bone loss), though specific biomechanical thresholds are unclear. Studies indicate each degree increase in glenoid retroversion raises PSI risk by 17%.<br /><br />Arthroscopic findings frequently show posterior labral lesions (up to 57%) and associated injuries such as SLAP, PASTA, and reverse HAGL. Surgical treatment—primarily arthroscopic capsulolabral repair—demonstrates good return-to-sport (RTS) rates: ~85% for throwers and 93% good/excellent stability in contact athletes, with a substantial proportion returning at the same competitive level.<br /><br />Surgical techniques discussed include capsulolabral plication with or without anchors, knotless repairs, and closure of the rotator interval to optimize stability without restricting external rotation. Typical portals (e.g., Hora 7) and steps such as tissue release and abrasion are highlighted.<br /><br />In summary, PSI is a complex clinical entity requiring tailored diagnosis and management based on etiology, sport type, and anatomical factors, with arthroscopic repair showing promising functional outcomes.

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(The Difficult Anterior RCT: A Guided Tour of a Perfect Subscapularis Repair)

Keywords

posterior shoulder instability

PSI

arthroscopic capsulolabral repair

glenoid retroversion

scapular dyskinesia

Jerk test

Push-Pull test

posterior labral lesions

throwing athletes

contact athletes