Posterior shoulder instability
Matthew D. Williamsa and T. Bradley Edwardsb
Purpose of review
Posterior instability of the glenohumeral joint is a relatively
rare diagnosis that can be debilitating for the active patient.
Practicing orthopaedic surgeons should be attentive when
evaluating patients with shoulder instability to reduce
misdiagnosis and treatment delay. This review will include
recent reports on the evaluation, treatment, and basic
science of posterior shoulder instability.
Recent findings
Laxity testing during physical examination of the shoulder is
critical in obtaining a correct diagnosis: positive results
correlate to the reproduction of instability symptoms and not
necessarily to pain or side-to-side differences. Arthroscopic
and open surgical techniques are effective for posterior
instability with average success rates of 89%. Thermal
capsulorrhaphy techniques result in inferior outcomes
compared to other techniques and their efficacy has been
questioned. Biomechanical studies show decreased
posterior glenohumeral translation with rotator interval
closure and suggest including this as a part of stabilization
procedures. Electromyographic studies support the
importance of periscapular muscle strengthening in
treatment of shoulder instability.
Summary
Appropriate treatment of posterior shoulder instability
begins with accurate diagnosis. Surgery is appropriate for
instability if conservative treatment fails and both open and
arthroscopic techniques are effective. Surgical procedures
are evolving as the understanding of glenohumeral
biomechanics improves.
Keywords
posterior instability, shoulder
Curr Opin Orthop 18:386–390. ß 2007 Lippincott Williams & Wilkins.
a
Foundation for Orthopedic Athletic and Reconstructive Research, University of
Texas Medical Center, Houston, Texas, USA and bFondren Orthopedic Group, LLP,
Houston, Texas, USA
Correspondence to T. Bradley Edwards, MD, Fondren Orthopedic Group, LLP,
7401 South Main Street, Houston, TX 77030-4509, USA
Tel: +1 713 799 2300; fax: +1 713 794 3378; e-mail: bemd@fondren.com
Current Opinion in Orthopaedics 2007, 18:386–390
ß 2007 Lippincott Williams & Wilkins
1041-9918
386
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Introduction
Posterior shoulder instability is a challenging condition
to diagnose and treat. Diagnosis is difficult because of the
few cases that present for evaluation and treatment.
Posterior instability makes up only 5% of cases of
shoulder instability [1,2]. Proper treatment is difficult
due to the multifactorial nature of shoulder instability
that may include both soft-tissue and bony components.
Clear understanding of glenohumeral anatomy and
biomechanics is fundamental to effective treatment.
Furthermore, knowledge of the spectrum of surgical
options including both open and arthroscopic procedures
is required for success. This review will detail literature
reports on the evaluation and treatment of posterior
shoulder instability published in the past year.
Classification
Degree, direction, cause, and volition are used to classify
posterior shoulder instability. Fixed posterior shoulder
dislocation and recurrent posterior shoulder subluxation
describe the degree of posterior instability [3]. The
direction of instability is described as unidirectional,
bidirectional, and multidirectional [4,5]. Traumatic and
atraumatic instability characterize the cause.
The more common traumatic posterior instability may
result from one memorable event or be secondary to
additive microtrauma over time. Repetitive trauma in
athletes, such as that which may be suffered by offensive
linemen on a football team, may lead to posterior
instability. Axial stress with the arm flexed, adducted,
and internally rotated predisposes them to posterior
instability [6,7]. Also at risk for developing posterior
instability are overhead athletes (i.e. throwers), swim-
mers, tennis players, and golfers [8,9].
Voluntary dislocators may subluxate or completely dis-
locate the glenohumeral joint at will [10]. Habitual
voluntary dislocators often have secondary gain issues
and respond poorly to surgical intervention; these
patients should be treated nonoperatively. Conversely,
nonhabitual patients who can voluntarily dislocate by
placing their shoulders in an at-risk position may respond
well to surgery [11]. The majority of patients, however,
present with involuntary subluxation causing pain and
decreased performance from trauma.
Presentation and evaluation
Patients with posterior instability will more commonly
complain of pain rather than instability and the symptoms
 Posterior shoulder instability Williams and Edwards 387

occur during activity. Weakness or fatigue of the shoulder Figure 1 Bernageau view of an offensive lineman with
symptomatic recurrent posterior instability
with activity is also reported. Determining when the
patient becomes symptomatic (i.e. in the follow-through
after pitching) is a key to appropriate diagnosis.

A thorough physical examination including inspection,

palpation, and manual testing of the shoulder including
motion, strength, and laxity should be completed on all
patients. Raebrox et al. [12] described a physical exam
finding suggestive of recurrent positional posterior dis-
location of the shoulder: a skin dimple over the postero-
medial deltoid. This sign is associated with posterior
instability with 67% sensitivity and 92% specificity. The
contralateral shoulder should also be thoroughly evalu-
ated for comparison to the involved side. In addition,
evaluation for generalized ligamentous laxity should be
completed. Specific tests for posterior laxity and instabil-
ity include the posterior stress, posterior drawer, the load
and shift, and the jerk test [1,2,13]. Bahk and colleagues
[13] reviewed the clinical applications of shoulder
instability testing and recommend that positive tests
be based on the reproduction of instability symptoms
or positive apprehension during examination. Although
pain may be a component of a patient’s complaints, pain
Note the posterior glenoid rim fragment.
with laxity testing does not necessarily confirm a diag-
nosis of instability. Furthermore, side-to-side differences
should not be used to substantiate a suspected diagnosis of on the etiology. Eighty percent of patients with atrau-
instability since asymptomatic athletes routinely dis- matic instability improved with physical therapy in a
play different degrees of laxity between their dominant study by Burkhead and Rockwood [15]. Two recent
and nondominant shoulders [13]. studies using electromyographic analysis evaluated
muscle contraction about the shoulder in patients with
Imaging documented glenohumeral instability compared to nor-
Appropriate imaging coupled with a conclusive physical mal controls. Both studies demonstrated altered scapu-
examination provides the best opportunity for accurate lohumeral rhythm and muscle-contraction patterns.
diagnosis and successful treatment. Plain radiographs These patterns may occur as a result of instability or
should be obtained and include an anteroposterior view, in an attempt to compensate for instability and stabilize
a scapular outlet view, and an axillary view. Although the glenohumeral joint. Both studies stress the import-
often normal, these views may demonstrate bony avul- ance of muscle strengthening and dynamic scapular
sions or reverse Hill–Sachs lesions. In our practice stabilizing therapy for conservative management of
instability is further assessed using a glenoid profile view shoulder instability [16,17].
as described by Bernageau et al. [14] for glenoid bone loss
(see Fig. 1). If the suspected diagnosis is related to soft- Operative intervention
tissue injury then magnetic resonance arthrography is Surgical treatment for posterior shoulder instability is used
the diagnostic test of choice. However, if glenoid bone only after failure of a supervised program of physical
loss is appreciated on plain films or bony abnormality is therapy. Recent reports of open [18,19], arthroscopic
suspected, then computerized tomography arthrography [9], and comparison studies [20] have been published.
should be used. Computerized tomography scanning Wolf et al. [18] reported on a retrospective review of
better delineates bone quality, fracture extent, and glenoid 44 shoulders at a mean follow-up of 7.6 years. An open
morphology (i.e. dysplasia) than magnetic resonance capsular shift was completed in all 44 patients with capsu-
imaging. lolabral repair in 18. At final follow-up 84% were satisfied
with their outcome. Poor results were related to the pre-
Nonoperative treatment sence of chondral lesions at the time of surgery and to an
The initial treatment of posterior shoulder instability age of greater than 37 at the time of the procedure.
should be nonoperative with a trial of physical therapy
and activity modification. Strengthening of periscapular In another report of open posterior capsulolabral repair
stabilizer muscles results in high success rates depending Rhee and colleagues [19] documented a 92% success rate.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 388 Shoulder
Thirty shoulders were reviewed retrospectively. A con-
comitant labral tear was found in only five patients
whereas posterior capsular laxity was the prevailing lesion
in 100% of the patients. Over a mean 30-month follow-up
an overall 13% recurrence rate was described. When
voluntary dislocators were removed from the results
the recurrence rate decreased to 8%. The authors con-
clude that involuntary posterior instability is due prim-
arily to capsular laxity and that open capsular plication
reliably restores function and stability.
Arthroscopic posterior stabilization was reported by
Bradley et al. [9] in the largest published series of
patients with unidirectional posterior instability. One
hundred shoulders were treated initially with a conser-
vative-therapy protocol that failed; 53% had a distinct
traumatic event. Forty-four underwent capsulolabral pli-
cation without suture anchors, 39 capsulolabral plication
with suture anchors, and 17 capsulolabral plication with
suture anchors and plication sutures. At the time of
surgery 66% were noted to have posterior capsular laxity,
and 57% had an element of labral injury (either a com-
plete or incomplete tear). Eighty-nine percent of patients
returned to sports, with 67% returning to their preinjury
level. Eight of the 11 failures opted for revision surgery
and two-thirds had signs of inferior or multidirectional
instability at the time of revision. Also, 75% of the failures
were treated with only plication sutures without suture
anchors due to the lack of obvious labral injury. Potential
pitfalls noted in this report were the positive correlation
of failure with incorrect diagnosis and poor repair
strength. Overall, arthroscopic posterior capsular stabil-
ization was concluded to be an effective procedure.
Bottoni and colleagues [20] published a retrospective
review of 31 shoulders, 19 treated arthroscopically and
12 open. All patients failed an initial course of physical
therapy. Open procedures included labral repair using
suture anchors and posterior capsulorrhaphy. Arthro-
scopic stabilization included labral repair with suture
anchors, capsular plication, and rotator interval closure.
One patient in each group reported recurrent instability
following surgery and three patients (one open and
two arthroscopic) reported a fair outcome hampered by
activity limitation and pain. Twenty-six patients had a
good or excellent outcome and returned to previous
activities. In conclusion, anatomic capsulolabral repairs
through open or arthroscopic approaches yield improve-
ment in stability and function.
Technical notes
Over the past year three technical notes concerning the
treatment of recurrent posterior shoulder instability have
been published: two arthroscopic procedures and one open
procedure. Costouros et al. [21] present an alternate
arthroscopic viewing portal to improve visualization of
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the posteroinferior capsule. The trans-rotator cuff portal
allows a superior-to-inferior view of the posterior glenoid
and labral repair through the anterior and posterior portals.
Five patients treated using this accessory portal were
presented with excellent results at an average 24-month
follow-up.
Krackhardt et al. [22] present an arthroscopic modifi-
cation of the McLaughlin procedure [23]. The subsca-
pularis tendon is mobilized and attached to the bed of
the reverse Hill–Sachs lesion using suture anchors. The
defect is filled with the subscapularis tendon preventing
recurrent dislocation from mechanical impingement.
Posterior shoulder instability associated with glenoid
bone loss requires glenoid augmentation using a bone
block [24,25]. Arciero and Mazzocca [26] describe a
technique of obtaining a bone block locally from the
posterior acromion for reconstruction of the posterior
glenoid. Five patients treated using this technique with
short-term follow-up demonstrated improved stability.
Thermal capsulorrhaphy
The benefits of thermal capsulorrhaphy may not be
outweighed by the risks that include treatment failure,
capsular destruction, neurovascular injury, and articular
cartilage damage [27,28]. Based on literature review,
Miniaci and Codsi [27] recommend situations in which
thermal devices should not be used or should be used
with restraint. Thermal capsulorrhaphy is associated
with a high failure rate in multidirectional instability in
patients without superior labrum, anterior-to-posterior, or
Bankart lesions. Primary posterior shoulder instability
in patients with a voluntary positional component is a
contraindication to using thermal devices. The efficacy
of thermal treatment in patients with unidirectional
instability and associated superior labrum, anterior-to-
posterior, or Bankart lesions is currently undetermined.
Finally, treatment of microinstability in the throwing
athlete is associated with mixed results using thermal
capsulorrhaphy and it should be used with caution [27].
Figure 2 (a) Arthroscopic view of a posterior Bankart lesion and
(b) completed arthroscopic capsulolabral repair
Reprinted with permission from Gartsman GM. Shoulder arthroscopy.
Philadelphia: WB Saunders, 2003. pp. 96, 99.
 Posterior shoulder instability Williams and Edwards 389

Figure 3 Preoperative and postoperative images of posterior instability treated with iliac-crest-bone block

(a) Posterior glenoid bone loss in a patient with symptomatic posterior subluxation, (b) postoperative anteroposterior view of autogenous iliac crest
bone block placement to the posterior glenoid, and (c) postoperative axillary view.

In a report by Massoud and colleagues [29] 13 patients Treatment decision-making

with voluntary shoulder instability treated with radiofre-
quency capsular shrinkage were discussed. After a mean
follow-up of 45 months, poor results were documented in
69% of patients and one transient axillary nerve palsy.
Despite the difficult nature of treating this group of
patients, the high occurrence of inferior results makes
radiofrequency capsular shrinkage an unacceptable
alternative.
Rotator interval closure
Imbrication of the rotator interval has been shown to
decrease glenohumeral translation in the antero-posterior
plane [30]. Two biomechanical studies were performed
to test the changes in glenohumeral motion effected by
isolated closure of the rotator interval. Yamamoto et al.
[31] described a superior–inferior rotator interval stitch
similar to that performed arthroscopically. Interval
closure resulted in a decrease in external rotation and
abduction with concomitant reduction in anterior–
posterior translation. The authors contend that routine
rotator interval closure should be added to capsulolabral
repairs and imbrication procedures to improve outcomes
of stabilization procedures. Plausnis and colleagues [32]
also studied glenohumeral mechanics following rotator
interval closure, but the procedure was completed
arthroscopically. Their results were contradictory to
previous works in that the interval closure significantly
reduced anterior translation but not posterior translation.
Regardless of the differences in outcome from other
investigations the authors contend that interval closure
should be further investigated and used to augment
capsulolabral tightening procedures.
Lesions responsible for posterior shoulder instability
must be accurately diagnosed for successful treatment.
Accurate diagnosis depends on clinical examination and
appropriate imaging studies to demonstrate the extent of
soft-tissue and/or bony injuries. Successful treatment
depends on selecting the appropriate surgical procedure
to address the identified lesion. Isolated posterior
instability associated with a posterior Bankart lesion is
treated with arthroscopic Bankart repair using suture
anchors (see Fig. 2) [33]. Instability secondary to capsular
laxity without labral injury is addressed using an arthro-
scopic posterior capsular shift. Trauma leading to glenoid
fracture and bone loss with symptomatic posterior
instability is treated with open surgery. A posterior bone
block (autogenous iliac crest bone graft) procedure with
medial capsular repair as necessary is the option of choice
in our practice (see Fig. 3). Bony abnormalities such as
severe humeral retroversion or posterior glenoid retro-
version are addressed with osteotomy.
Conclusion
Posterior glenohumeral instability is a spectrum of con-
ditions that makes assessment, diagnosis, and treatment
of these patients challenging. Appropriate physical exam-
ination of glenohumeral instability and an understanding
and application of these test results is fundamental to
obtaining a correct diagnosis. Imaging modalities are
selected on the basis of physical exam findings and will
delineate soft-tissue from bony injuries to assist in choos-
ing the proper surgical procedure. The advancement of
arthroscopic techniques has improved the results of these
procedures such that they are equally effective at restor-
ing stability and function to patients with posterior

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 390 Shoulder
instability. Thermal capsulorrhaphy is associated with
numerous complications and has a record of poor and
inconsistent results. Surgeons should weigh the risks
and benefits of using these devices for treating instability
and consider arthroscopic or open capsulolabral repairs
secondary to their proven record. Finally, advances in
the understanding of glenohumeral biomechanics are still
being made and will modify current and future surgical
procedures.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 422).
1 Millett PJ, Clavert P, Hatch GFR, Warner JJP. Recurrent posterior shoulder
 instability. J Am Acad Orthop Surg 2006; 14:464–476.
A thorough review of recurrent posterior shoulder instability including anatomical
considerations, evaluation, treatment, and complications of surgical procedures.
2 Robinson CM, Aderinto J. Recurrent posterior shoulder instability – current
concepts review. J Bone Joint Surg Am 2005; 87:883–892.
3 Hawkins RJ, Koppert G, Johnson G. Recurrent posterior instability of the
shoulder. J Bone Joint Surg Am 1984; 66:169–174.
4 Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of
bi-directional glenohumeral instability: two to five-year follow-up. J Shoulder
Elbow Surg 2001; 10:28–36.
5 Neer CS, Foster CR. Inferior capsular shift for involuntary inferior and
multidirectional instability of the shoulder. J Bone Joint Surg Am 1980;
62:897–908.
6 Kaplan LD, Flanigan DC, Norwig J, et al. Prevalence and variance of shoulder
injuries in elite collegiate football players. Am J Sports Med 2005; 33:1142–
1146.
7 Escobedo EM, Richardson ML, Schulz YB, et al. Increased risk of posterior
glenoid labrum tears in football players. Am J Roentgenol 2007; 188:193–
197.
8 Faustin CM, Rassi GE, Toulson CE, et al. Isolated posterior labrum tear in a
golfer: a case report. Am J Sports Med 2007; 35:312–315.
9 Bradley JP, Baker CL III, Kline AJ, et al. Arthroscopic capsulolabral recon-
 struction for posterior instability of the shoulder: a prospective study of 100
shoulders. Am J Sports Med 2006; 34:1061–1071.
A prospective study of 100 shoulders with unidirectional posterior instability
treated arthroscopically, the largest series in the literature. The report reviews
proper patient evaluation, delineates arthroscopic capsulolabral repair with and
without suture anchors, and describes a rehabilitation protocol. At 27 months after
the operation stability, pain, and function improved with 89% of patients returning
to athletics.
10 Rowe CR, Pierce DS, Clark JG. Voluntary dislocation of the shoulder:
a preliminary report on a clinical, electromyographic and psychiatric study
of twenty-six patients. J Bone Joint Surg Am 1973; 26:445–460.
11 Fuchs B, Jost B, Gerber C. Posterior-inferior capsular shift for the treatment of
recurrent, voluntary posterior subluxation of the shoulder. J Bone Joint Surg
Am 2000; 8882:16–25.
12 Raebrox AV, Campbell B, Ramesh R, Bunker T. The association of subacromial
 dimples with recurrent posterior dislocation of the shoulder. J Shoulder Elbow
Surg 2006; 15:591–593.
A new physical exam finding is described that is associated with recurrent
positional posterior shoulder dislocation.
13 Bahk M, Keyurapan E, Tasaki A, et al. Laxity testing of the shoulder: a review.
 Am J Sports Med 2007; 35:131–144.
A thorough review of laxity testing of the glenohumeral joint. Biomechanical
principles of shoulder instability and normal shoulder laxity are discussed. Clinical
techniques for the assessment of laxity are described, and these tests are
evaluated as to their role in clinical practice and decision-making.
14 Bernageau J, Patte D, Dabeyre J, Ferrane J. Value of glenoid profile in recurrent
luxations of the shoulder. Rev Chir Orthop Reparatrice Appar Mot 1976;
62:142–147.
15 Burkhead WZ, Rockwood CA. Treatment of instability of the shoulder with an
exercise program. J Bone Joint Surg 1992; 74:890–896.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
16 Illyés A, Kiss RM. Electromyographic analysis in patients with multidirectional
 shoulder instability during pull, forward punch, elevation and overhead throw.
Knee Surg Sports Traumatol Arthrosc 2006; epub ahead of print.
A comparison of muscle activation and scapulohumeral motion in patients with
glenohumeral instability compared with controls. Aberrant contraction and motion
patterns are attributed to protective mechanisms or an attempt to regain joint stability.
17 Matias R, Pascoal AG. The unstable shoulder in arm elevation: a three-
dimensional and electromyographic study in subjects with glenohumeral
instability. Clin Biomech 2006; 21:S52–S58.
18 Wolf BR, Strickland S, Williams RJ, et al. Open posterior stabilization for
recurrent posterior glenohumeral instability. J Shoulder Elbow Surg 2005;
14:157–164.
19 Rhee YG, Lee DH, Lim CT. Posterior capsulolabral reconstruction in posterior
shoulder instability: deltoid saving. J Shoulder Elbow Surg 2005; 14:355–
360.
20 Bottoni CR, Franks BR, Moore JH, et al. Operative stabilization of posterior
shoulder instability. Am J Sports Med 2005; 33:996–1002.
21 Costouros JG, Clavert P, Warner JJP. Trans-cuff portal for arthroscopic
 posterior capsulorrhaphy. Arthroscopy 2006; 22:1138.e1–1138.e5.
A trans-rotator cuff viewing portal is presented that provides improved visualization
of the posterior glenoid for posterior labral repair and capsulorrhaphy procedures.
22 Krackhardt T, Schewe B, Albrecht D, Weise K. Arthroscopic fixation of
 the subscapularis tendon in the reverse Hill–Sachs lesion for traumatic
unidirectional posterior dislocation of the shoulder. Arthroscopy 2006;
22:227.e1–227.e6.
An arthroscopic version of the McLaughlin procedure is presented for filling
reverse Hill–Sachs lesions. Twelve procedures are reported with no major
complications.
23 McLaughlin H. Posterior dislocation of the shoulder. J Bone Joint Surg Am
1952; 34:584–590.
24 Fronek J, Warren RF, Bowen M. Posterior subluxation of the glenohumeral
joint. J Bone Joint Surg Am 1989; 71:205–216.
25 Sirveaux F, Leroux J, Roche O, et al. Surgical treatment of posterior instability
of the shoulder using an iliac bone block or an acromial pediculated bone
block: outcome in eighteen patients. Rev Chir Orthop Reparatrice Appar Mot
2004; 90:411–419.
26 Arciero RA, Mazzocca AD. Posterior acromial bone block augmentation
 for the treatment of posterior glenoid bone loss associated with recurrent
posterior shoulder instability. Tech Shoulder Elbow Surg 2006; 7:210–217.
A technique for posterior glenoid reconstruction for bony deficiency is described
using a local bone graft from the posterior acromion. The paper provides a
thorough description of the procedure but little follow-up data on the patients
treated with this procedure.
27 Miniaci A, Codsi MJ. Thermal capsulorrhaphy for the treatment of shoulder
 instability. Am J Sports Med 2006; 34:1356–1363.
Thermal capsulorrhaphy is reviewed in the context of basic science and the clinical
implications of its use. Clinical studies are discussed and compared. Specific
recommendations are made for limiting the use of thermal capsulorrhaphy in
certain conditions.
28 Fenn P, Hersch J. Posterior instability of the shoulder following thermal
 capsulorrhaphy for multidirectional instability: a case report. Arthroscopy
2007; 23:226.e1–226.e4.
A case report describing posterior capsular laxity following thermal capsulorrhaphy.
Capsular destruction is a serious complication of using thermal devices.
29 Massoud SN, Levy O, Copeland SA. Radiofrequency capsular shrinkage for
 voluntary shoulder instability. J Shoulder Elbow Surg 2007; 16:43–48.
A report of 13 patients treated with a thermal device for voluntary shoulder
instability. Although voluntary dislocators are a difficult patient group to treat,
the high incidence of poor results makes radiofrequency shrinkage a nonviable
alternative. Overall poor results were reported in 69% of the patients.
30 Harryman DT, Sidles JA, Harris SL, Matsen FA. The role of the rotator interval
capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am
1992; 74:53–66.
31 Yamamoto N, Itoi E, Tuoheti Y, et al. Effect of rotator interval closure on
 glenohumeral stability and motion: a cadaveric study. J Shoulder Elbow Surg
2006; 15:750–758.
A biomechanical study evaluating the changes in glenohumeral motion produced
by closure of the rotator interval. The authors reproduced the findings of earlier
studies that interval closure does reduce antero-posterior translation. A recom-
mendation is made to add routine interval closure to arthroscopic stabilization
procedures.
32 Plausnis D, Bravman JT, Heywood C, et al. Arthroscopic rotator interval
closure: effect of sutures on glenohumeral motion and anterior-posterior
translation. Am J Sports Med 2006; 34:1656–1661.
33 Gartsman GM. Glenohumeral instability. In: Gartsman GM, editor. Shoulder
arthroscopy, 1st ed. Philadelphia: Saunders; 2003. pp. 81–118.