Anterior Shoulder Instability Treated Through an Anterior Arthroscopic Approach

Abstract

Anterior shoulder instability remains one of the main indications for shoulder surgery. We present a modified way of treating anterior shoulder instability in the beach-chair position from an anterior arthroscopic approach through the rotator interval. This technique opens the rotator interval, which increases the working area and allows us to work without cannulae. Through this approach, we can treat all injuries comprehensively and, if necessary, switch to other arthroscopic techniques used for instability such as arthroscopic Latarjet or anterior ligamentoplasties.

Technique Video

Video 1

Video technique. Anterior left shoulder instability treated through an anterior arthroscopic approach. We carry out the surgery with the patient under general and locoregional anesthesia (interscalene block). We place the patient in the beach-chair position with the arm in antepulsion parallel to the body; we do not use traction. We begin by placing D (vision) and E portals, according to Lafosse's nomenclature.

Anterior shoulder instability remains one of the main indications for shoulder surgery. Several studies are showing that arthroscopic Bankart repair is successful in treating traumatic anterior shoulder instability without bone loss (Fig 1 A and B).¹ On the other hand, to deal with Hill-Sachs lesions (Fig 1 A and B), remplissage is a safe procedure with low complication rates, low recurrent instability rates, good patient outcome scores, and minimal loss of range of motion compared with many of the alternative techniques.^2,3

Fig 1.

Left shoulder magnetic resonance imaging showing the lesions. (A) Axial plane: Bankart lesion. (B) Sagittal plane: Hill-Sachs lesion. (BL, Bankart lesion; HH, Humeral head; HSL, Hill-Sachs lesion.)

There are many ways to treat shoulder instability arthroscopically.^1,3 The main author of this article has encouraged the use of the anterior approach in shoulder arthroscopy as it allows us, from the lateral portal, to handle the intra-articular and subacromial area at the same time, thus allowing us to assess the shoulder as a whole, without having to change portals.

We present a modified way of treating anterior shoulder instability in the beach-chair position from an anterior arthroscopic portal through the rotator interval. Opening the rotator interval increases the working area and allows us to work without cannulae. On the other hand, using this anterior arthroscopic approach, we can treat all injuries comprehensively and, if necessary, switch to other arthroscopic techniques used for instability such as arthroscopic Latarjet or anterior ligamentoplasties.⁴

Surgical Technique

Our surgical technique is demonstrated in Video 1. The indications and contraindications for this anterior arthroscopic approach are the same as those for the classical arthroscopic treatment of anterior shoulder instability without significant glenoid bone loss.^1,2 The pearls and pitfalls are summarized in Table 1. The advantages and disadvantages are listed in Table 2.

Table 1.

Pearls and Pitfalls of Treating Anterior Shoulder Instability Treated Through an Anterior Arthroscopic Approach

Pearls

Pitfalls

•We place the patient in the beach-chair position with the arm in antepulsion parallel to the body; we do not use traction. •The subacromial space is accessed first. •The coracoacromial ligament must be identified because it will be our superior landmark to remove the rotator interval. •We recommend following the coracoacromial ligament from lateral until its insertion in the glenoid process and start opening the rotator interval from this reference to anterior. •The entire rotator interval should be cleaned and the base of the coracoid should be exposed to avoid postoperative pain and stiffness. •The conjoint tendon must be exposed and the clavipectoralis fascia dissected to facilitate work on the anterior shoulder. •A lasso-mattress type suture is performed with a direct-pass clamp. To do this, we pass one of the threads with a loop lasso and the other one with a direct pass. •It should be carried out on an anteroinferior percutaneous portal, just lateral to the conjoint tendon, to have direct access to the anteroinferior glenoid area. •To increase anterior shoulder stability, we perform the arthroscopic extracapsular stabilization technique for anterior shoulder instability–BLS ("between glenohumeral ligaments and subscapularis tendon”). •In the case of anteroinferior instability, the order of knotting is as follows: anteroinferior plication, posteroinferior plication, anterior plication (from lower to upper), and remplissage. •In the knotting, as these are lasso-mattress sutures, the post should always be the longest of the threads, as this is the one that has not passed through the loop.

•The first few times this technique is performed, there is a risk for supraspinatus, biceps, and subscapularis lesions at the opening of the rotator interval. •Avoid going more medial to the coracoid process because of the risk of brachial plexus and vessel lesions.

Table 2.

Advantages and Disadvantages of Treating Anterior Shoulder Instability Treated Through an Anterior Arthroscopic Approach

Advantages

Disadvantages

•Opening the rotator interval increases the working area and allows us to work without cannulae. •Using this anterior arthroscopic approach, we can treat all injuries comprehensively. •No traction is used. •If necessary, we can switch to other arthroscopic techniques used for instability such as arthroscopic Latarjet or anterior ligamentoplasties. •We expose the conjoint tendon and dissect the clavipectoralis fascia to facilitate work on the anterior shoulder. •The anteroinferior percutaneous portal, just lateral to the conjoint tendon, allows the anteroinferior anchor to be placed toward the center of the glenoid, where there is usually more bone stock.

•More complex technique •Learning curve •A very careful approach to avoid damaging supraspinatus, biceps, and subscapularis

We carry out the surgery with the patient under general and locoregional anesthesia (interscalene block) (Fig 2). We place the patient in the beach-chair position with the arm in antepulsion parallel to the body; we do not use traction.

Fig 2.

Patient in the beach-chair position; no traction used.

Anterior Arthroscopic Shoulder Approach

We begin by placing D (vision) and E portals, according to Lafosse's nomenclature (Fig 3).⁵ We first access the subacromial space.

Fig 3.

Arthroscopic portals, left shoulder. Viewing portal D. Initial working portal E.

We identify the coracoacromial ligament, which will be our superior landmark (Fig 4A) to remove the rotator interval. We recommend following the coracoacromial ligament from lateral until its insertion in the coracoid process and start opening the rotator interval from this reference to lateral (Fig 4B). For the opening of the rotator interval, we remove the coracohumeral ligament and the superior glenohumeral ligament (Fig 5). As we go deeper, care should be taken not to injure the long head of the biceps (Fig 6), and we should take advantage of this moment to explore the biceps tendon for any pathology that may require treatment. Subsequently, we should clean the entire rotator interval and expose the base of the coracoid (Fig 7) to avoid postoperative pain and stiffness. We must expose the conjoint tendon and dissect the clavipectoralis fascia to facilitate work on the anterior shoulder. Care should be taken to avoid damage to the supraspinatus, biceps, and subscapularis tendons when opening the rotator interval. We must avoid going more medial to the coracoid process because of the risk of brachial plexus and vessel lesions. We move to the intra-articular space with the camera between the long head of the biceps and supraspinatus (Fig 8). Once we have opened the rotator interval, we must perform an exhaustive diagnostic arthroscopy to rule out other articular injuries.

Fig 4.

Beach-chair position, left shoulder. View portal D. We identify the coracoacromial ligament (CAL), which will be our superior landmark (A) to remove the rotator interval (RI). We recommend following the coracoacromial ligament from lateral until its insertion in the glenoid process and start opening the rotator interval from this reference to anterior (B). (CAL, coracoacromial ligament; RI, rotator interval; S, supraspinous.)

Fig 5.

Beach-chair position, left shoulder. View portal D. For the opening of the rotator interval, we remove the coracohumeral ligament and the superior glenohumeral ligament.

Fig 6.

Beach-chair position, left shoulder. View portal D. For the opening of the rotator interval, we remove the coracohumeral ligament and the superior glenohumeral ligament. As we go deeper, care should be taken not to injure the long head of the biceps (LHB), and we should take advantage of this moment to explore the biceps tendon for any pathology that may require treatment.

Fig 7.

Beach-chair position, left shoulder. View portal D. We should clean the entire rotator interval and expose the base of the coracoid to avoid postoperative pain and stiffness. We must expose the conjoint tendon and dissect the clavipectoralis fascia to facilitate work on the anterior shoulder. (C, coracoid basis; CT, conjoint tendon; S, supraspinous.)

Fig 8.

Beach-chair position, left shoulder. View portal D. We move to the intra-articular space with the camera between the long head of the biceps and supraspinatus. Once we have opened the rotator interval, we must perform an exhaustive diagnostic arthroscopy to rule out other articular injuries. (AL, anterior labrum; G, glenoid; HH, humeral head; LHB, long head of the biceps; S, supraspinous.)

Posteroinferior Plication

Using a vision-D portal with the arm in retropulsion position, we expose the posterior labrum (Fig 9A). We perform a posteroinferior percutaneous portal, and without using cannulas, we place an Iconix 1.4 anchor (Stryker) at 7 o'clock (Fig 9B). A lasso-mattress⁶ type suture is performed with a direct suture passer. To do this, we pass one of the threads with a lasso loop and the other one with a direct pass (Video 1).

Fig 9.

Beach-chair position, left shoulder. View portal D. With the arm in retropulsion position, we expose the posterior labrum (A). We perform a posteroinferior percutaneous portal, and without using cannulas, we place an Iconix 1.4 anchor (Stryker) at 7 o'clock (B). A lasso-mattress type suture is performed with a direct suture passer. To do this, we pass one of the threads with a loop lasso and the other one with a direct pass. (G, glenoid; HH, humeral head; PC, posterior capsule; PL, posterior labrum.)

Remplissage Preparation

To treat the Hill-Sachs lesion, an Iconix 2.3 anchor (Stryker) is prepared for remplissage. We pass the 4 threads through the tissue but will not tie the knots until the end of the surgery. The implant is placed in the part closest to the cartilage of the Hill-Sachs defect (Fig 10).³ The reason for placing the anchor at this time is because if it is placed after repairing the anterior labrum, we would have less space and we could damage the labral repair.

Fig 10.

Beach-chair position, left shoulder. View portal D. To treat the Hill-Sachs lesion, an Iconix 2.3 anchor (Stryker) is prepared for remplissage. We pass the 4 threads through the tissue but will not tie the knots until the end of the surgery. The implant is placed in the part closest to the cartilage of the Hill-Sachs defect. The reason for placing the anchor at this time is because if it is placed after repairing the anterior labrum, it could damage the repair. (G, glenoid; HH, humeral head; HSL, Hill-Sachs lesion; PL, posterior labrum.)

Anterointerior Plication

We perform an anteroinferior percutaneous portal, just lateral to the conjoint tendon (Fig 11A), to have direct access to the anteroinferior glenoid area. This portal allows the anteroinferior anchor to be placed toward the center of the glenoid, where there is usually more bone stock. The inferior glenohumeral ligament–labrum complex is detached from the underlying glenoid using a periosteotome (Fig 11B). After checking that the anterior labrum can be mobilized and reduced to its anatomic area, the anteroinferior labrum is repaired with an Iconix 1.4 anchor (Stryker) at 5 o'clock.

Fig 11.

Beach-chair position, left shoulder. View portal D. We perform an anteroinferior percutaneous portal (A), just lateral to the conjoint tendon, to have direct access to the anteroinferior glenoid area. This portal allows the anteroinferior anchor to be placed toward the center of the glenoid, where there is usually more bone stock. The detachment of the anterior labrum is performed with a periostotome to lift it to the underside of the glenoid (B). After checking that the anterior labrum can be mobilized and reduced to its anatomic area, the anteroinferior labrum is repaired with an Iconix 1.4 anchor (Stryker) at 5 o'clock. (AL, anterior labrum; G, glenoid; HH, humeral head.)

To increase anterior shoulder stability, we perform the arthroscopic extracapsular stabilization technique for anterior shoulder instability–BLS ("between glenohumeral ligaments and subscapularis tendon”) described by Brzóska et al.⁷ We use a lasso-mattress type suture with a direct-pass suture retriever.⁶

Anterior Plication

A lasso-mattress⁶ type suture is performed with a direct suture passer. To do this, we pass one of the threads with a lasso loop and the other one with a direct pass (Video 1). In total, for the entire anterior labrum, we use 2 to 3 anchors (Fig 12), depending on the tear type. In this step, we must be careful not to place too many implants and avoid placing them too high, as this can cause stiffness in the biceps tendon.

Fig 12.

Beach-chair position, left shoulder. View portal D. To repair the anterior labrum, we repeat the same process as for the posterior labrum with a lasso-mattress suture. In total, for the entire anterior labrum, we use 2 to 3 anchors, depending on the tear type. In this step, we must be careful not to place too many implants and avoid placing them too high, as this can cause stiffness in the biceps tendon. (AL, anterior labrum; G, glenoid; HH, humeral head; ST, subscapularis tendon.)

Knot Tying

In anteroinferior instability, the order of knot tying is as follows (Fig 13):

• 1.Anteroinferior plication
• 2.Posteroinferior plication
• 3.Anterior plication (from lower to upper)
• 4.Remplissage

Fig 13.

Beach-chair position, left shoulder. View portal D. In the case of anteroinferior instability, the order of knotting is as follows: anteroinferior plication (1), posteroinferior plication (2), anterior plication (3) (from lower to upper), and remplissage (4) as these are lasso-mattress sutures. The post should always be the longest of the threads, as this is the one that has not passed through the loop.

As these are lasso-mattress sutures. The post should always be the longest of the threads, as this is the one that has not passed through the loop.

Postoperative Management

The patient must wear a sling for 2 weeks, which can be removed for eating and grooming. Two weeks after surgery, the rehabilitation is started. Passive and self-assisted exercises are started after 15 days, active exercises after 4 weeks, and stretching and muscle strengthening after 3 months.

Discussion

The anterior arthroscopic approach, although it is not well known, has many advantages for the shoulder surgeon. The main author of this article uses it routinely in almost all of its shoulder arthroscopies. In this approach, we routinely perform a wide opening of the rotator interval, so it increases the working area and allows us to work without cannulae.

As we do it in the beach-chair position, it allows us to switch to other arthroscopic techniques used for instability such as arthroscopic Latarjet or anterior ligamentoplasties if necessary.

In the treatment of shoulder instability, we routinely perform a posteroinferior plication due to the posterior capsular distension that occurs in most anterior shoulder instabilities, thus favoring the humeral head to be centered in the glenoid. In this respect, Werner et al.⁸ described, after conducting a cadaver study, that posteromedial capsular plication reduces translation and engagement similarly to remplissage, without any restriction in motion.

On the other hand, in our comprehensive approach to shoulder instability, we use, in the anteroinferior capsular plication, the BLS method described by Brzóska et al.,⁷ which consists of an anterior extracapsular stabilization "between glenohumeral ligaments and subscapularis tendon" (BLS). The BLS technique is an effective method to treat anterior shoulder instability in patients without significant glenoid bone loss. It was shown that this technique provides significant improvement in shoulder function without reducing shoulder range of motion.⁷ As described by the authors, this nonanatomic technique relies on the augmentation of the damaged anterior wall soft tissues by a part of the subscapularis muscle.⁷

Another important aspect of the technique is the percutaneous anterior portal that we perform lateral to the conjoint tendon. Through this portal, we can orient our anteroinferior anchor above the subscapularis to find the center of the glenoid, where there is usually more bone stock.

In conclusion, we present a modified way of treating anterior shoulder instability in the beach-chair position from an anterior arthroscopic portal through the rotator interval. The main advantage is that opening the rotator interval increases the working area and allows us to work without cannulae. On the other hand, with this anterior arthroscopic approach, we can treat all injuries comprehensively and, if necessary, switch to other arthroscopic techniques used for instability such as arthroscopic Latarjet or anterior ligamentoplasties.

Supplementary Data

Video 1

Video technique. Anterior left shoulder instability treated through an anterior arthroscopic approach. We carry out the surgery with the patient under general and locoregional anesthesia (interscalene block). We place the patient in the beach-chair position with the arm in antepulsion parallel to the body; we do not use traction. We begin by placing D (vision) and E portals, according to Lafosse's nomenclature.