Abstract
Passing suture during a Bankart repair can be a difficult task. A key component of a Bankart repair involves shifting the anteroinferior capsule and labrum superiorly. This technical note describes a new technique of reaching the inferior aspect of the Bankart lesion from posterior. Typical suture passers push the tissue further away. Using a SutureLasso through the low posterolateral portal allows one to push the tissue from inferior toward the suture anchor, making it simpler to advance the capsulolabral complex. Three suture anchors are used in the anteroinferior quadrant. The lowest suture anchor is the critical anchor for advancing the capsule and labrum. The SutureLasso is placed into the axillary recess through the low posterolateral portal, and the nitinol wire is advanced through the capsule and labrum, retrieving the suture and pulling it back through the tissue for tying with a sliding locking knot. This ensures good superior advancement of the tissue and helps obtain an optimal arthroscopic result in Bankart repair. Additional anchors are placed, and suture passage for the middle and superior anchors is then completed from anterior. The advancement and restoration of the tissue tightness provide the optimal components for an excellent result.
Anatomic Bankart repair has been shown to significantly decrease the risk of recurrent instability.1 The most difficult part of performing a Bankart repair is suture passage through the anteroinferior capsule and labrum. The goals are to reproduce the anatomy of the anteroinferior labrum and to restore the “bumper” of the capsulolabral complex by advancing the tissue, tightening up any plastic deformation that may have occurred, and firmly attaching it to the glenoid to prevent further dislocations and instability.2,3 Numerous devices for suture passage are available, but they all tend to push the tissue inferior or away from the desired direction of advancement. We describe our technique using the low posterolateral portal4 for insertion of a SutureLasso (Arthrex, Naples, FL). This allows the capsule to be reached at the 6-o'clock region and advanced directly toward the anchor. The low posterolateral portal is located 2 to 4 cm lateral and 4 to 5 cm inferior to the posterolateral corner of the acromion. Three standard double-loaded suture anchors are placed in the anteroinferior quadrant of the glenoid. Starting with the most inferior anchor, these sutures are passed in both mattress and simple fashion using a SutureLasso through the low posterolateral portal. Previously, this portal was described as being useful to place anchors for posterior and especially posteroinferior labral tears. This portal is also extremely useful for capturing inferior capsule and labrum near the 5- to 7-o'clock position to carry out a superior shift for increasing stability. This portal has been reproducible and safe in our hands in over 150 cases. In cases with glenoid bone loss, fractures, or engaging Hill-Sachs lesions, this technique can be used in conjunction with arthroscopic reduction and internal fixation or remplissage.5
Surgical Technique
A Bankart lesion confirmed by magnetic resonance imaging (Figs 1 and 2) after a history and physical examination suggests anterior shoulder dislocation and instability. Diagnostic arthroscopy is initiated through a standard posterior viewing portal (Video 1). Once labral pathology is identified, standard anterosuperolateral and anteroinferior portals6 are created through an outside-in technique. A cannula is placed in the anterosuperolateral portal. The surgeon elevates the anteroinferior labrum and capsule using an elevator, ensuring that the subscapularis muscle can be seen. This allows adequate advancement of the capsulolabral complex.2,3 The rim and neck of the glenoid are then abraded. Three double-loaded suture anchors can then be sequentially placed anteriorly in the glenoid in standard fashion by use of a spear, through the anteroinferior portal. The most inferior anchor is placed first at the 5-o'clock position in a right shoulder or the 7-o'clock position in a left shoulder.
Fig 1.
Preoperative magnetic resonance imaging of left shoulder: A fat-suppressed proton density–weighted axial image shows an edematous and irregular anteroinferior labrum (arrow) and adjacent capsular stripping (arrowhead) compatible with a soft-tissue Bankart lesion. (G, Glenoid; HH, Humeral Head)
Fig 2.
Preoperative magnetic resonance imaging of left shoulder: A T1-weighted coronal oblique image shows the anteroinferior labral tear (arrow) and plastic deformation of the inferior glenohumeral ligament (arrowhead). (G, Glenoid; HH, Humeral Head)
Then, while visualizing through the anterosuperolateral or posterior viewing portal, the surgeon creates the low posterolateral portal. A spinal needle is introduced approximately 2 to 4 cm lateral and 4 to 5 cm inferior to the posterolateral border of the acromion. The needle hugs the posterior surface of the humeral head and reaches the glenoid rim at a 45° angle. We prefer to make a small stab incision (2 mm) and then introduce the 90° SutureLasso (Arthrex, Naples, FL) alongside the spinal needle without a cannula (Fig 3). It is helpful to have the tip of the lasso follow the needle into the joint in a spoon fashion, rather than having the handle parallel to the needle. From this location, the SutureLasso can then be used to purchase as much inferior capsule as desired without much difficulty. Increased traction on the arm from the assistant often provides improved visualization.
Fig 3.
Left shoulder in lateral decubitus position showing placement of spear through low posterolateral portal. Measurements are 2 to 4 cm lateral and 4 to 5 cm inferior to the posterolateral corner of the acromion.
Capsular tissue is purchased by use of the SutureLasso for any tissue in the range of the 5- to 6-o'clock area that one desires to advance (Fig 4). The nitinol wire from the lasso is then advanced and is pulled through the anterosuperolateral portal with a suture grasper. One suture from the inferior anchor is also taken through the anterosuperolateral portal either with the nitinol wire or individually. The suture is then pulled back out the low posterolateral portal with the other end of the nitinol wire that was still in the lasso. This is repeated, and 2 different strands of suture are retrieved with the nitinol wire. This makes 1 pair of sutures a mattress repair and 1 a simple suture repair. The sutures can be retrieved back to the anterior cannula and tied. We use the SMC knot, but any secure knot can be used. An alternative way of tying would be to pull the 2 sutures out the low posterolateral portal and tie without a cannula. Both sutures must be pulled through the skin with a suture retriever at the same time to avoid a tissue bridge that would prevent knot tying. Once the inferior-most sutures are tied, the next 2 anchors can be sequentially inserted and the sutures passed with the lasso through the anteroinferior portal. They are retrieved and tied in a similar fashion through the anterosuperolateral portal.
Fig 4.
Arthroscopic findings. (A) The anteroinferior labral tear and capsular stripping are visualized through the anterosuperolateral portal. (B) The SutureLasso is inserted through the low posterolateral portal and reaches the 6-o'clock position. (C) The lasso is passed through the inferior capsule and labrum toward the suture anchor. (D) The finished repair is shown, as visualized through the posterior portal after the nitinol wire pulls the suture through the labrum and is tied with a sliding locking knot. (Ant Inf, anteroinferior.) (G, Glenoid; HH, Humeral Head)
Discussion
Success in Bankart repair requires advancement of the capsule and labrum.2,3,7 This technique shows a safe and relatively simple way to advance the inferior capsule and labrum toward the suture anchor. The safety and anatomy of the low posterolateral portal have been previously described, as have the reliability and reproducibility. This portal typically allows access to the posteroinferior and inferior glenoid. The senior author has regularly used this portal in the past for placement of suture anchors in the posteroinferior glenoid for posterior Bankart repairs and type VIII, IX, and X SLAP tears.8
This article summarizes a technique that we have used on a regular basis to perform capsulorrhaphy in an optimal manner, in which the inferior capsular tissue is advanced superiorly (Tables 1 and 2). The 6-o'clock area is difficult to access from the usual anteroinferior and anterosuperolateral portals, where suture passers tend to push tissue further away (inferior or posterior) rather than advancing it toward the suture anchor. The low posterolateral portal is an excellent portal for advancing the inferior capsule and labrum toward the lowest anchor in a Bankart repair.
Table 1.
Tips and Pearls of Procedure
| Identify the Bankart lesion with magnetic resonance imaging and then arthroscopically mobilize the anteroinferior labrum and capsule so that the subscapularis muscle is seen when lifting the labrum. |
| Insert the lowest anteroinferior anchor at the 5-o'clock position in a right shoulder or 7-o'clock position in a left shoulder. |
| Place the spinal needle at the low posterolateral portal, 2-4 cm lateral and 4-5 cm inferior to the posterior lateral border of the acromion. |
| Use a SutureLasso to follow the needle into the axillary pouch below the inferior labrum, and advance the lasso through some of the capsule and then the inferior labrum. |
| Retrieve the nitinol wire through the anterosuperolateral cannula with the corresponding suture or sutures and pull them back out to the low posterolateral portal; then tie each pair of sutures as desired. |
Table 2.
Indications and Contraindications for Low Posterolateral Portal in Bankart Repair
| Indications |
| Inferior labral tears and plastic deformation of inferior capsule |
| Tears not reachable from anteroinferior portal |
| Use in conjunction with anteroinferior portal for passing sutures |
| Contraindications |
| Bankart lesions that do not have an inferior component |
| Large bony Bankart lesions not amenable to suture repair |
| Chronic bone loss >25% |
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Steps in the surgical technique for advancing the inferior labrum in a Bankart repair in a left shoulder through the low posterolateral portal.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Steps in the surgical technique for advancing the inferior labrum in a Bankart repair in a left shoulder through the low posterolateral portal.