Abstract
Arthroscopic repair of lesions of the superior labrum and biceps anchor has been shown to provide good to excellent results. We describe a simplified arthroscopic surgical technique using a single knotless anchor with a mattress suture configuration. This technique provides an effective and reproducible method to reattach and re-create the normal appearance of the superior labrum and biceps anchor in a time-efficient manner without the need for knot tying.
Tears of the superior aspect of the glenoid labrum involving the biceps anchor were first described in 1985 by Andrews et al.1 in a series of overhead athletes. These injuries were later classified by Snyder et al.2 in 1990. The most common of these lesions is the type II lesion, characterized by superior labral fraying and a tear of the labral tissue with the biceps root from the superior glenoid margin. Arthroscopic management of these lesions has shown good to excellent results.
Our technique involves the use of a single posteriorly placed knotless suture anchor (PushLock; Arthrex, Naples, FL) with a mattress suture configuration. More extensive posterior tears may require an additional anchor. This technique allows compression of the repair and a buried, low-profile suture without the need for knot tying.
Technique
We prefer the lateral decubitus position for shoulder arthroscopy. The patient is positioned with 2 back supports to allow a 30° posterior tilt. The arm is supported with 10 lb of traction in 30° to 40° of abduction and 10° to 20° of flexion. A standard posterior portal is made with a blunt trocar. A diagnostic arthroscopy is then performed. A standard anterior portal is made by an inside-out technique to probe and confirm the lesion. The superior glenoid is debrided with the use of a small shaver and rasp over the entire length of the lesion up to the articular glenoid margin to enhance healing.
An anterolateral interval portal is established using a needle above the biceps tendon and anterior to the supraspinatus tendon. The skin is then incised, and a 7-mm cannula (Clear-Trac; Smith & Nephew Endoscopy, Andover, MA) is inserted over a switching stick using a reusable obturator. This is the working portal for the procedure. A drill hole for the anchor is then created at the 11:30 clock-face position (right shoulder) inclined 45° to the glenoid surface (Fig 1, Video 1).
Fig 1.
Bone socket creation from anterolateral interval portal. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; HH, humeral head; LHB, long head of biceps; SL, superior labrum.)
A nonabsorbable suture (FiberStick; Arthrex) is loaded into a 25° (left curve for right shoulder) SutureLasso (Arthrex). This is then passed through the posterosuperior labrum at the 11:45 clock-face position (right shoulder), and the free strand of the suture is passed through the device, beneath the labrum and into the joint (Fig 2). The suture is then retrieved through the anterior portal (Fig 3). Care is taken not to remove the suture completely from the device.
Fig 2.
First pass of SutureLasso through labrum with 25° left SutureLasso. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; HH, humeral head; LHB, long head of biceps; SL, superior labrum.)
Fig 3.
Anterior limb of suture end retrieved through anterior portal. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; HH, humeral head; LHB, long head of biceps; SL, superior labrum.)
The SutureLasso is withdrawn from the labrum and stepped posteriorly 5 to 7 mm (Fig 4) before being reinserted through the labrum more posteriorly at the 11:15 clock-face position (right shoulder) (Fig 5). An arthroscopic grasper is then used to retrieve the other end of the suture, also through the anterior portal (Fig 6). This creates an oblique mattress suture through the labrum (Fig 7).
Fig 4.
SutureLasso remaining in joint to create mattress configuration. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; HH, humeral head; LHB, long head of biceps; SL, superior labrum.)
Fig 5.
Second pass of SutureLasso through labrum 5 to 7 mm posterior to first. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; HH, humeral head; LHB, long head of biceps; SL, superior labrum.)
Fig 6.
Posterior limb of suture end retrieved through anterior portal. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; HH, humeral head; LHB, long head of biceps; SL, superior labrum.)
Fig 7.
(A) Oblique mattress positioning (anterior limb passed beneath superior labrum and posterior limb passed through superior labrum). (B) Mattress suture with labrum secured over joint surface due to both limbs of suture being passed beneath superior labrum. (C) Oblique mattress suture securing labrum in anatomic position. (G, glenoid; LHB, long head of biceps; SL, superior labrum.)
Both limbs of the suture are shuttled out of the anterolateral portal, and the PushLock anchor is loaded (Fig 8). The anchor is inserted into the pre-prepared drill hole and impacted into the glenoid while tensioning the sutures (Fig 9). The sutures are cut short to minimize irritation that may be seen with nonabsorbable knots (Fig 10). The labrum and biceps anchor are lastly probed to confirm the adequacy of the repair (Fig 11).
Fig 8.
Both suture ends shuttled into anterolateral portal. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; HH, humeral head; LHB, long head of biceps; SL, superior labrum.)
Fig 9.
Knotless anchor insertion. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; HH, humeral head; LHB, long head of biceps; SL, superior labrum.)
Fig 10.
Sutures cut leaving a low profile. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; HH, humeral head; LHB, long head of biceps; SL, superior labrum.)
Fig 11.
Final repair probed to confirm fixation. Arthroscopic view of a right shoulder, with the patient in the lateral decubitus position, with a 30° arthroscope in the posterior viewing portal and with an anterolateral (clear cannula) working portal and standard anterior (blue cannula) portal. (A, anterior portal; AL, anterolateral portal; G, glenoid; LHB, long head of biceps; SL, superior labrum.)
Our rehabilitation protocol consists of a shoulder immobilizer for the first 3 weeks with passive elbow range-of-motion and shoulder pendulum exercises. We do not allow resisted biceps contraction for 6 weeks.
Discussion
Numerous techniques have been developed to repair type II SLAP lesions, with no single technique showing superiority over the rest. Knotless anchor repairs have been shown to have comparable fixation strength to simple suture repair.3 Furthermore, when combined with a horizontal mattress suture configuration, they better re-create the normal superior labral anatomy.4, 5 In addition, the use of a mattress suture with a single anchor has been shown to be biomechanically superior to the use of simple sutures with either 1 or 2 anchors.6
There is some concern that placement of an anterior anchor may tension the anterior capsulolabral structures. This may result in a decrease in external rotation range of motion. A biomechanical study of the peel-back mechanism of failure has shown no advantage to the placement of an anterior anchor.7
Our technique for the repair of type II SLAP lesions anatomically reconstructs the superior labrum and biceps pulley. It is a biomechanically sound construct that prevents the peel-back mechanism of failure without the potential for knot irritation. In addition, by not having to remove the SutureLasso and shuttle the second limb of the suture, it has proved a time-efficient technique. Table 1 reviews the indications, contraindications, key points, tips, pearls, pitfalls and risks, and aftercare.
Table 1.
Indications, Contraindications, Key Points, Tips, Pearls, Pitfalls and Risks, and Aftercare
| Indications |
| Detached superior labrum |
| Contraindications |
| Midsubstance tear |
| Tear extending into biceps tendon |
| Key points |
| A standard posterior viewing portal, standard anterior shuttling portal, and anterolateral interval working portal are used. |
| Use of a knotless anchor reduces the potential for knot irritation. |
| A mattress suture configuration better re-creates the superior labral anatomy. |
| The posterior anchor prevents the peel-back mechanism. |
| Tips |
| The technique can be performed with the patient in the lateral decubitus or beach-chair position. |
| The drill hole for the anchor should be performed before suture passing. |
| An oblique mattress suture better re-creates the anatomy. |
| More extensive tears may require an additional anchor. |
| Pearls |
| Suture passage should be positioned on either side of the drill hole. |
| Care should be taken not to remove the suture completely from the suture passer after the first pass. |
| Pitfalls and risks |
| Suture passage of both limbs under the labrum leads to a nonanatomic repair with the labrum secured over the joint surface. |
| Poor positioning of the anterolateral portal can lead to difficulty in anchor insertion. |
| Aftercare |
| Sling for 6 wk |
| No resisted biceps contraction for 6 wk |
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Simplified knotless mattress repair of type II SLAP lesions. The patient is positioned in the lateral decubitus position with 10 lb of traction. A standard posterior viewing portal is made, and diagnostic arthroscopy performed. A standard anterior portal is then made using an inside-out technique. The superior glenoid is debrided. An anterolateral interval portal is established using an outside-in technique, and a 7-mm cannula is inserted. This is the working portal for the procedure. A drill hole for the anchor is then created at the 11:30 clock-face position (right shoulder) inclined 45° to the glenoid surface. A nonabsorbable suture is loaded into a 25° (left curve for right shoulder) suture passer. This is then passed through the posterosuperior labrum at the 11:45 clock-face position (right shoulder), and the free strand of the suture is retrieved through the anterior portal. The suture passer is withdrawn from the labrum and stepped posteriorly 5 to 7 mm before being reinserted through the labrum more posteriorly at the 11:15 clock-face position (right shoulder). An arthroscopic grasper is then used to retrieve the other end of the suture, also through the anterior portal. This creates an oblique mattress suture through the labrum. Both limbs of the suture are shuttled out of the anterolateral portal, and the knotless anchor is loaded. The anchor is inserted into the pre-prepared drill hole and impacted into the glenoid while tensioning the sutures. The sutures are cut short, and the labrum and biceps anchor are lastly probed.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Simplified knotless mattress repair of type II SLAP lesions. The patient is positioned in the lateral decubitus position with 10 lb of traction. A standard posterior viewing portal is made, and diagnostic arthroscopy performed. A standard anterior portal is then made using an inside-out technique. The superior glenoid is debrided. An anterolateral interval portal is established using an outside-in technique, and a 7-mm cannula is inserted. This is the working portal for the procedure. A drill hole for the anchor is then created at the 11:30 clock-face position (right shoulder) inclined 45° to the glenoid surface. A nonabsorbable suture is loaded into a 25° (left curve for right shoulder) suture passer. This is then passed through the posterosuperior labrum at the 11:45 clock-face position (right shoulder), and the free strand of the suture is retrieved through the anterior portal. The suture passer is withdrawn from the labrum and stepped posteriorly 5 to 7 mm before being reinserted through the labrum more posteriorly at the 11:15 clock-face position (right shoulder). An arthroscopic grasper is then used to retrieve the other end of the suture, also through the anterior portal. This creates an oblique mattress suture through the labrum. Both limbs of the suture are shuttled out of the anterolateral portal, and the knotless anchor is loaded. The anchor is inserted into the pre-prepared drill hole and impacted into the glenoid while tensioning the sutures. The sutures are cut short, and the labrum and biceps anchor are lastly probed.