Abstract
Using a posterolateral portal in passing and tying the inferior knot allows good labral reduction and adequate capsular shift to treat anterior shoulder instability. In this technique, the most inferior anchor is placed through a low anterolateral portal. A penetrating grasper is introduced from a posterolateral portal situated 2 to 3 cm distal and lateral to the viewing portal. This portal is used to pass the 2 limbs of the anchor suture as inferior as possible through the labrum and capsule close to 6 o'clock position to form the 2 limbs of the first mattress suture. Finally, knot tying is performed through this posterolateral portal, thus allowing better superior shift of the capsulolabral tissue. The other 2 anchor sutures are passed and tied through the low anterolateral portal.
In the most cases of anterior shoulder instability, the labrum is injured in the zone between 3 and 6 o'clock (for the right shoulder).1 To achieve an adequate repair, it is essential to place the inferior anchor and its suture as inferior as possible.2
Several portals and arthroscopic techniques were employed for placing the inferior anchor and its suture. However, the access to the inferior parts of the glenoid and labrum is still limited by the classical anterolateral portal.2 In our technique, we used a posterolateral portal to pass the inferior anchor suture and tie it. We believe that the posterolateral portal allows better access to the 6 o'clock region during suture passing, which is difficult to reach by other anterior portals. Nevertheless, knot tying from the posterolateral portal allows better capsular shift by pushing the tissues more superiorly, thus improving the capsular plication.
Surgical Technique
Thirty-four patients were operated on in our institute from January 2011 to November 2013. The technique received approval of the institutional ethical committee. A written consent was signed by all patients. All the patients had a classic Bankart lesion due to a traumatic anterior shoulder dislocation (at least 3 episodes). Patients with bony Bankart, greater tuberosity fracture, SLAP lesion, rotator cuff tear, humeral avulsion of the inferior glenohumeral ligament, capsular tear, multidirectional instability, large engaging Hill-Sachs, anterior glenoid deficiency, neurological disorders, or previous surgery of the shoulder were excluded.
All surgeries are performed in the beach chair position. A standard posterior portal is used as a viewing portal. A low anterolateral portal is located under vision using a spinal needle and situated in the rotator interval as close as possible to the superior border of the subscapularis tendon to allow access to the anterior and inferior parts of the glenoid. An 8-mm shoulder cannula is then inserted. Routine diagnostic arthroscopy is performed in the beginning of the procedure in every case to assess the humeral head subluxation, the presence and engagement of Hill-Sachs lesion, and the condition of the labrum humeral head. The anterior labrum is released with a dissector and then a shaver is used to debride the labral edge and a rasp is used to decorticate the anterior glenoid neck.
A soft tissue penetrating suture passer is then inserted to penetrate the capsule and labrum at its inferior part and a traction loop is inserted and retrieved from the cannula of the low anterolateral portal. The most inferior anchor is placed through the low anterolateral portal. A posterolateral portal situated 2 to 3 cm distal and lateral to the viewing portal is then created under vision using a spinal needle as a guide to confirm proper access to the inferior part of the labrum and capsule (Fig 1). No cannula is inserted through this portal.
Fig 1.
A photographic image of the right shoulder. The posterolateral portal situated 2-3 cm distal and lateral to the viewing portal. (*, posterior viewing portal; **, posterolateral portal.)
While pulling the traction loop, a contralateral penetrating grasper is used to pass the anchor sutures; in a right shoulder, a device with its tip directed to the left is used and vice versa for the left shoulder. One of the two limbs of the anchor suture is passed through the labrum and the second limb is passed through the capsule at the anterior band of the inferior glenohumeral ligament 0.5 cm away from the first limb. These 2 limbs are passed as close as possible to the 6 o'clock position to form the 2 limbs of the inferior mattress suture. Both limbs of the suture of the anchor are retrieved from the posterolateral portal, and a sliding fisherman's knot is used followed by 3 alternating half hitches. The knot pusher is introduced from the posterolateral portal to push the knot producing the bumper effect and shifting the capsule upward (Fig 2). The pearls and pitfalls of passing and tying the inferior anchor suture are shown in Table 1.The remaining 2 anchors are inserted and their sutures are passed and tied from the anterolateral portal. Figure 3 shows the anterior labrum at the end of the procedure. The technique is shown in Video 1.
Fig 2.
Arthroscopic view of Bankart repair from the posterior portal of the right shoulder in the beach chair position. Insertion of the inferior anchor and its suture. (A) The anchor is inserted from the low anterolateral portal. (B) While pulling the traction loop, a penetrating grasper is used to penetrate the labrum as inferior as possible and used to pass one limb of the anchor suture. (C) A penetrating grasper penetrates the capsule as inferior as possible to pass the second limb of the anchor suture. (D) Both limbs after passing through the labrum and capsule. (E) The knot pusher is passed from the posterolateral portal to tie the knot. This pushes the tissues further upward and assists in creating a good bumper at the anteroinferior labrum and assists in having a good capsular shift. (F) Arthroscopic view from the posterior portal after tying the inferior anchor suture.
Table 1.
Pearls and Pitfalls of Passing and Tying the Inferior Anchor Suture
| Posterolateral portal placement | The posterolateral portal is situated 2-3 cm distal and lateral to the viewing portal. |
| Use a spinal needle to confirm the trajectory of the portal before it is created. | |
| Passing the inferior anchor suture | Use a traction suture passed from the low anterolateral portal to avoid injury to the structures at the inferior glenoid. The traction suture should be pulled while passing the anchor sutures. |
| Use a contralateral penetrating grasper to pass the anchor sutures as close as possible to the 6 o'clock position. | |
| The first limb is passed through the labrum. | |
| The second limb is passed through the capsule 0.5 cm from the first limb at the anterior band of the inferior glenohumeral ligament. Do not go deep in the tissues after penetrating the capsule to avoid injuring the neurovascular structures at the inferior glenoid. | |
| Tying the inferior anchor suture | Tying of the first inferior mattress suture is done from the posterolateral portal. This allows more upward shift of the tissues and creates a better bumper. |
Fig 3.
Arthroscopic view of Bankart repair of the right shoulder from the posterior portal in the beach chair position. The capsulolabral tissue after the 3 anchors are inserted and their sutures are tied.
Discussion
There are 2 important benefits of using this technique; the first is that the posterolateral portal allows better access to the inferior capsulolabral tissue. Thus using this portal to pass the inferior sutures allows placing the sutures as close as possible to the 6 o'clock position. The second advantage that we consider as the hallmark of using this technique is performing knot tying from the posterolateral portal that allows pushing the tissues during the knot tying rather than pulling them that happens when tying the knot from the anterolateral portal. This allows good reduction of the labrum to the glenoid and creates a good bumper. In addition, it allows better upward shift of the capsule. The advantages and risks of the technique are summarized in Table 2.
Table 2.
The Advantages and Risks of Using the Posterolateral Portal for Passing the Inferior Anchor Suture
| Advantages | Passing the inferior anchor suture as close as possible to the 6 o'clock position |
| Knot tying from the posterolateral portal allows “pushing” not “pulling” the tissues and thus better capsular shift | |
| Risks | Injury to the neurovascular structures at the inferior glenoid that can be avoided by: |
| Using a traction suture | |
| After penetrating the capsule during passing the second limb do not go with the penetrating grasper deep in the tissues |
Although the traditional Bankart lesion is between 3 and 6 o'clock (90° based on circle concept),1 the capsular redundancy in many cases is between the anterior and posterior bands of the inferior glenohumeral ligament (axillary pouch). Thus the site of the inferior anchor suture is crucial to allow anatomical reduction of the capsuloligamentous tissue and also to produce adequate capsular shift and thus eliminate capsular redundancy.3 The low anterolateral portal provides limited access to the inferior glenoid and capsuloligamentous tissue possibly due to the obliquity of the approach.2 In this study, we used a posterolateral portal to improve the access to the inferior capsulolabral structures. Capsular laxity is one of the factors associated with recurrent anterior shoulder dislocation.4 Thus we believe that adding superior shift of the capsule will add to the stability. We also believe that the use of a traction suture enhances the safety of the procedure. It allows pulling on the capsulolabral tissue before passing the anchor suture and thus minimizes the risk of injury to the neurovascular structures at the inferior glenoid. The traction suture also allows better superior shift of the capsular tissues.
Davidson and Rivenburgh5 conducted a cadaveric study on 6 paired shoulders to assess the safety of the 7 o'clock portal. Mirouse and Nourissat6 described the split posterior portal between the infraspinatus and teres minor on 8 cadavers. These studies concluded that the posterolateral portal can be used safely for passing the anchor sutures. Cvetanovich et al.7 described a surgical technique where a posterolateral portal was developed 4 cm lateral to the posterolateral border of the acromion following the trajectory of the posterior border of the clavicle laterally. The inferior anchor was placed through the posterolateral portal. A spectrum was passed from the posterior portal and the capsule grasped anterior to the anchor. In our technique, the anchor was introduced from the anterolateral portal but the anchor suture was passed through the posterolateral portal. We believe that passing the anchor suture from the posterolateral portal allows the suture to be as close as possible to the 6 o'clock position.
Adams et al.8 described a posterolateral portal located 2 to 4 cm lateral and 4 to 5 cm inferior to the posterolateral border of the acromion. A spinal needle was introduced to reach the glenoid rim at an angle of 45°. They placed 3 anchors through the anteroinferior portal. A SutureLasso introduced from the posterolateral portal was used to grasp tissues from the 5 to 7 o'clock position. Then the sutures were tied from the anterior cannula or through the posterolateral portal. In our technique, knot tying was always performed from the posterolateral portal. Thus the knot pusher acts by pushing (not pulling) the tissues further superiorly producing better capsular shift and a bumper effect. This is of special consideration in patients with absent and thin labrum where capsular volume will play an important role in stabilizing the shoulder.
We believe that using the posterolateral portal for passing the inferior anchor suture and knot tying provides better access to the inferior labrum and allows better recreation of the anteroinferior bumper.
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Supplementary Data
The technique used in a patient with a Bankart lesion in the right shoulder. The position of the patient is shown. The posterior portal is used as the viewing portal. Arthroscopic examination is performed initially in all our operations. After the labrum is released, a traction loop is inserted from the low anterolateral portal followed by the first anchor from the same portal. A posterolateral portal is then created and a contralateral penetrating grasper is used to pass the 2 limbs of the inferior anchor sutures, one through the labrum and the second through the capsule. Both limbs are retrieved from the posterolateral portal and a knot pusher is introduced from the same portal to tie the inferior mattress suture. The remaining 2 anchors are inserted and their sutures tied from the anterolateral portal.
References
- 1.Creighton R.A., Romeo A.A., Brown F.M., Hayden J.K., Verma N.N. Revision arthroscopic shoulder instability repair. Arthroscopy. 2007;23:703–709. doi: 10.1016/j.arthro.2007.01.021. [DOI] [PubMed] [Google Scholar]
- 2.Frank R.M., Mall N.A., Gupta D. Inferior suture anchor placement during arthroscopic Bankart repair: Influence of portal placement and curved drill guide. Am J Sports Med. 2014;42:1182–1189. doi: 10.1177/0363546514523722. [DOI] [PubMed] [Google Scholar]
- 3.Castagna A., Garofalo R., Conti M., Flanagin B. Arthroscopic Bankart repair: Have we finally reached a gold standard? Knee Surg Sports Traumatol Arthrosc. 2016;24:398–405. doi: 10.1007/s00167-015-3952-6. [DOI] [PubMed] [Google Scholar]
- 4.Boileau P., Villalba M., Héry J.-Y., Balg F., Ahrens P., Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88:1755–1763. doi: 10.2106/JBJS.E.00817. [DOI] [PubMed] [Google Scholar]
- 5.Davidson P.A., Rivenburgh D.W. The 7-o'clock posteroinferior portal for shoulder arthroscopy. Am J Sports Med. 2002;30:693–696. doi: 10.1177/03635465020300051101. [DOI] [PubMed] [Google Scholar]
- 6.Mirouse G., Nourissat G. The split portal: Description of a new accessory posterior portal for arthroscopic shoulder instability procedures. Knee Surg Sports Traumatol Arthrosc. 2016;24:625–629. doi: 10.1007/s00167-015-3911-2. [DOI] [PubMed] [Google Scholar]
- 7.Cvetanovich G.L., McCormick F., Erickson B.J. The posterolateral portal: Optimizing anchor placement and labral repair at the inferior glenoid. Arthrosc Tech. 2013;2:e201–e204. doi: 10.1016/j.eats.2013.02.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Adams B.A., Garrett W.H., Wright G.B., Khan M.W., Taylor J.B., Nord K.D. A novel technique for advancing the inferior labrum in a Bankart repair. Arthrosc Tech. 2013;2:e121–e124. doi: 10.1016/j.eats.2012.12.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
The technique used in a patient with a Bankart lesion in the right shoulder. The position of the patient is shown. The posterior portal is used as the viewing portal. Arthroscopic examination is performed initially in all our operations. After the labrum is released, a traction loop is inserted from the low anterolateral portal followed by the first anchor from the same portal. A posterolateral portal is then created and a contralateral penetrating grasper is used to pass the 2 limbs of the inferior anchor sutures, one through the labrum and the second through the capsule. Both limbs are retrieved from the posterolateral portal and a knot pusher is introduced from the same portal to tie the inferior mattress suture. The remaining 2 anchors are inserted and their sutures tied from the anterolateral portal.