Abstract
Recurrent shoulder instability in young contact athletes has been well established. The importance of bipolar bone loss in instability has come to the forefront in terms of proper management of this condition. It remains controversial, however, which patients would be better served with an arthroscopic versus open procedure and when additional procedures may reduce the risk of failure (i.e., remplissage). We present our arthroscopic technique of a panlabral repair with concomitant remplissage using the double-pulley technique. The purpose of this article is to provide insight into obtaining superior visualization while reviewing surgical pearls and pitfalls to efficiently perform a panlabral repair and remplissage.
One of the most important factors when considering surgery for shoulder instability is evaluating for glenoid and/or humeral head bone loss. Although routine radiographs should be obtained, including true anteroposterior, axillary lateral, and scapular-Y views, advanced imaging is often necessary. Anterior glenoid bone loss is known to be a risk factor for failure of a standard arthroscopic soft-tissue procedure. There has not been a consensus as to what constitutes “critical” bone loss. Burkhart and De Beer1 reported than an inverted pear–shaped glenoid predicted failure of an arthroscopic stabilization. Similarly, Boileau et al.2 reported that glenoid bone loss greater than 25% resulted in a 75% risk of failure after arthroscopic stabilization. Shaha et al.3 reported that bone loss greater than 13.5% led to a clinically significant decrease in Western Ontario Shoulder Instability scores consistent with an unacceptable outcome, even in patients who did not sustain a recurrent dislocation.
There are several methods available to measure glenoid bone loss. We prefer the “perfect circle” method as described by Huijsmans et al.4 Huysmans et al.5 showed that the inferior glenoid has the shape of a true circle. A perfect circle is drawn over the inferior two-thirds of the glenoid aligning with the intact posterior-inferior portion on sagittal computed tomography or magnetic resonance imaging. After the diameter is calculated, the size of the defect is measured with a line parallel to that used for the glenoid diameter. The measured amount of glenoid bone loss is divided by the full diameter of the glenoid and multiplied by 100 to give the percentage of bone loss.
Traditionally, open Bankart repair with capsular shift was thought to be superior, with some authors reporting failure rates of less than 5%.6, 7, 8, 9 However, when open Bankart repair is compared with arthroscopic surgery using modern techniques and suture anchors, there is little difference in the redislocation rate.9, 10, 11 This report describes a technique of arthroscopic stabilization for post-traumatic shoulder instability associated with an anterior Bankart lesion with bone loss, a posterior labral lesion, and a large Hill-Sachs defect (Video 1). Typical arthroscopy portals are adjusted for superior visualization and access to the labral tears, and accessory portals allow efficient, easy access for labral mobilization and glenoid preparation. Table 1 shows the surgical tips for efficiency in this procedure.
Table 1.
Surgical Pearls
| Glenoid bone loss should be accurately quantified. |
| The surgeon should identify whether a Hill-Sachs lesion engages the anterior glenoid. |
| It is critical to accurately place the portals (Fig 1). |
| The posterior portal should be made slightly more superior and lateral than usual; this allows one to work below the portal more easily. |
| A spinal needle should be used to accurately place both anterior portals within the rotator interval. |
| The anterior-superior portal should enable easy access to the lowest position necessary for the case. |
| The accessory posterior-lateral portal should be made using a spinal needle and provide the exact trajectory needed to the most posterior-inferior position on the glenoid. |
| Viewing from the anterior-medial portal (in the interval) provides a full view of the glenoid. |
| Placing a Liberator or other mobilizing instrument from the anterior-superior portal provides a great trajectory to the anterior and posterior labrum. |
| Thorough mobilization of the labrum is paramount to a tension-free repair. |
| The anterior labrum should be mobilized enough to visualize the fiber of the subscapularis deep to the labrum. |
| A well-mobilized labrum should float up even with the glenoid edge. |
| The surgeon should use a chevron-shaped drill guide. |
| This enables the guide to easily sit on the glenoid face under axial load without slipping. |
| Medial placement of anchors should be avoided. |
| The surgeon should capture the capsule in addition to the labrum with sutures. |
| If tying arthroscopic knots, the surgeon should ensure they are docked on the side away from the articular cartilage to avoid abrasion to the humeral head. |
| Remplissage is performed. |
| The calcified layer within the Hill-Sachs lesion is removed. |
| The anchors are placed at the periphery of the lesion. |
| This allows the infraspinatus to fill the lesion, effectively excluding it from the glenohumeral joint. |
Surgical Technique
We begin with an examination of the patient under anesthesia comparing the operative shoulder with the normal shoulder before draping. After preparation and draping of the shoulder, we apply the STaR (Shoulder Traction and Rotation) Sleeve and 3-point shoulder traction tower (Arthrex, Naples, FL). In our opinion, this provides optimal visualization at the most inferior aspect of the glenohumeral joint because of its additional function of direct lateral traction.
Step 1
Figure 1 shows our standard portals drawn on the shoulder with bony landmarks outlined. We begin by establishing our posterior portal slightly more superior than a standard viewing portal. This not only provides good visualization but also enables us to use it as a working portal. It is much easier to use a suture-shuttling instrument below the cannula, hence our reasoning for placing the portal slightly more superior. A standard 4-mm 30° arthroscope is inserted, and diagnostic arthroscopy is performed.
Fig 1.
The patient is in the lateral position with the arm suspended in traction. Our standard portals and bony landmarks are shown drawn on the shoulder. We use the following portals for addressing anterior and posterior labral pathology: posterior portal (P), posterolateral portal (PL), anteromedial portal (AM), and anterosuperior portal (AS).
Step 2
After diagnostic arthroscopy has confirmed labral pathology, we place both of our anterior portals using an outside-in technique. The first is placed high and medial in the rotator interval, whereas the second is located laterally above the subscapularis within the interval (anterior-superior portal) (Fig 2). The cannulas resemble a double-barrel configuration. We do not penetrate the subscapularis to reach the inferior aspect of the glenoid.
Fig 2.
Lateral position, viewing from posterior portal. Ideal placement of the anterior portals is shown, resembling a double-barrel configuration. (B, biceps; G, glenoid; S, subscapularis.)
We then switch the arthroscope to visualize from the anterior aspect (anterior-medial portal), giving us an excellent view of the anterior bone loss and posterior pathology. Specific attention is given to assessing the degree of anterior bone loss and size of the Hill-Sachs lesion, not to mention whether the lesion is engaging or “off track.” Figure 3 shows anterior bone loss and a posterior labral tear.
Fig 3.
Lateral position, viewing from anterior-medial portal. (A) Anterior bone loss is evident to the left of the intact glenoid with an irregular surface. The anterior-superior cannula (ASC) is visualized to the left and intact glenoid (G) to the right. (B) A posterior labral tear is visualized (red blush). (G, glenoid; H, humeral head.)
Step 3
With the surgeon viewing from the anterior-medial portal, the anterior capsulolabral complex is completely mobilized from its most inferior-to-superior extent. We begin by inserting an angled Liberator (Arthrex) into the anterior-superior portal (Fig 4). This provides an excellent trajectory to the posterior labral tear and greatly facilitates mobilization. After thorough mobilization of the posterior labral tear, we turn our attention to mobilizing the anterior capsulolabral complex, which can be scarred down along the glenoid neck. One should be aware that if the appropriate angled device is not used, the labrum could be lacerated, creating a radial tear with 2 separate floating fragments. Once appropriate mobilization is obtained, the bony fragment and labrum will often “float” up to the level of the glenoid surface for a tension-free repair (Fig 5).
Fig 4.
Lateral position, viewing from anterior-medial portal. A Liberator (L) is introduced through the anterior-superior portal and is shown mobilizing the posterior labral tear. One should note the anterior labral tear and bone loss to the left. (G, glenoid.)
Fig 5.
Lateral position, viewing from anterior-medial portal with Liberator in anterior-superior portal. One should note the degree of appropriate mobilization of the anterior capsulolabral complex from the 5:30 clock-face position to the 2-o'clock position and prepared anterior glenoid bone bed (BB). (G, glenoid.)
Step 4
Once the capsulolabral complex is well mobilized, we prepare the glenoid bone to improve healing. Using a rasp (Arthrex) or motorized shaver, the surgeon removes the calcified layer often covering the native glenoid bone and creates a bleeding bone bed to facilitate healing. If using the shaver, he or she must avoid causing iatrogenic glenoid bone loss. Again, using the instrument within the anterior-superior portal provides great access to the anterior and posterior glenoid for preparation.
Step 5
At this point, we have mobilized the anterior and posterior labral tears and prepared a bleeding bone bed. We begin with repair of the posterior labrum because tightening the anterior labrum significantly limits the space available to work posteriorly. In general, we use knotless fixation to avoid sutures from eroding into the cartilage. To obtain an optimal trajectory to the posterior-inferior glenoid, we then establish a posterior-lateral portal off the posterolateral corner of the acromion using a spinal needle and switching stick. A small metal “percutaneous” cannula is then placed over the switching stick to ensure the appropriate trajectory. All of the suture anchor pilot holes can be drilled from this portal. Introducing the SutureLasso (Arthrex) into the original posterior portal, we then pierce the capsule and capture capsule and labral tissue approximately 5 mm below our first planned suture anchor. This effectively shifts the capsule and labrum superiorly to tighten the posterior capsulolabral complex. We then grasp the nitinol wire contained within the SutureLasso and deliver it out of the anterior-superior portal. An Arthrex FiberLink is shuttled through the SutureLasso back out of the posterior portal. This suture allows us to create a “luggage tag” stitch by simply passing the single end through the loop and removing tension. At this point, the chevron-shaped drill guide for a 2.9-mm SutureTak knotless anchor (Arthrex) is placed slightly on the glenoid face and axial load applied. In our opinion, the chevron-shaped guide provides a good fit on the edge of the glenoid, allowing it to also be used to displace the humeral head for optimal trajectory. After drilling, the single end of the FiberLink suture is loaded into the suture anchor and placed through the drill guide into position. We repeat this step as necessary, placing additional anchors approximately 5 mm apart to complete the posterior labral repair (Fig 6).
Fig 6.
Lateral position, viewing from anterior-medial portal. The repaired posterior labral tear is shown. One should note the metal cannula in the posterolateral working portal. (G, glenoid; L, posterior labrum.)
Step 6
After repair of the posterior labrum, we turn our attention to the anterior labral tear. While the surgeon is still viewing from the anterior-medial portal, the drill guide is introduced through the anterior-superior portal to the 5:30 clock-face position on the glenoid. In the event the appropriate trajectory cannot be reached, percutaneous insertion of the guide is applicable in this case. After drilling, a suture anchor already containing a FiberWire suture (Arthrex) is then inserted. Although we routinely use knotless fixation, in the presented case, we tied arthroscopic knots for technique purposes. One should keep in mind that knots must be placed far away from the articular surface to prevent abrasion of the cartilage. Using the SutureLasso, we penetrate just below the anterior band of the inferior glenohumeral ligament capturing capsule, remnant bone, and the entire labrum, and a suture is shuttled back through the tissue. Adequate tensioning of the redundant anterior aspect of the capsule, as well as repair of the anterior aspect of the labrum to the glenoid, is critical for the restoration of shoulder stability. A secure arthroscopic knot of choice is then tied. We repeat this step as necessary, placing additional anchors approximately 5 mm apart, always capturing tissue below where the anchor is to be placed. This ensures an appropriate shift of the anterior capsulolabral complex to its native position (Fig 7).
Fig 7.
Lateral position, viewing from anterior-medial portal. The complete anterior and posterior labral repair is shown. One should note the restored “bumper effect” provided by the repair. (G, glenoid; H, humeral head.)
Step 7
After repair of the posterior and then anterior labral tears, we turn our attention to the Hill-Sachs lesion. Given that our patient sustained approximately 17% anterior bone loss, we included a remplissage to reduce the risk of repeat dislocation. We used a double-pulley technique described originally by Wolf and Arianjam12 and modified by Koo et al.13 This double-pulley suture technique uses 2 anchors to inset the infraspinatus tendon into the entire Hill-Sachs defect with a broad footprint of fixation.
By use of the shaver, the calcified layer in the Hill-Sachs lesion is carefully removed. We then position 2 spinal needles to determine the angle of approach for the transtendon placement of the suture anchors. A pilot hole is created using a punch or drill. One preloaded anchor is placed anterior and another posterior within the defect. A single limb from each anchor is pulled out of the same portal, and these are tied to each other, creating an “air knot” (Fig 8). The other limbs of the suture anchors are then pulled to parachute the knot down on top of the infraspinatus. A blind arthroscopic knot is then tied, forcing the infraspinatus tendon into the Hill-Sachs defect, effectively eliminating it from the area of engagement (Fig 9). One could also visualize tying of the knot by placing the camera into the subacromial space if preferred.
Fig 8.
Double-pulley technique with 1 suture limb from each anchor tied in an air knot. The most superior (S) and inferior (I) limbs are pulled to parachute the knot down on top of the infraspinatus tendon. The free limbs are then tied down, forming a horizontal mattress configuration to compress the tendon into the Hill-Sachs defect.
Fig 9.
Lateral position, right shoulder, viewing from the anterior portal toward the Hill-Sachs defect, showing exclusion of the Hill-Sachs lesion. The white veil of tissue is the rotator cuff tendon pulled into the Hill-Sachs defect. The Hill-Sachs lesion is behind the veil of rotator cuff (RC). (H, humeral head.)
Discussion
One of the most important factors when considering surgery for shoulder instability is evaluating for glenoid and/or humeral head bone loss. The difficulty lies in determining the amount of bone loss that represents a clinically significant deficit. Burkhart and De Beer1 described that critical bone loss greater than 25% requires a bone augmentation, whereas Shaha et al.3 redefined critical bone loss as 13.5%, at which the Western Ontario Shoulder Instability score increased to rates consistent with a poor clinical outcome. Moreover, Burkhart and De Beer reported that during arthroscopy, the bare spot of the glenoid was a consistent reference point that was located almost exactly at the center of the circle defined by the inferior glenoid margin. In our experience, however, we have not found the bare spot to reliably sit at the anatomic center of the glenoid. In our practice and as reported by other authors, some patients do not have a bare spot, making this method inconsistent.14, 15 There are several techniques to estimate the degree of anterior bone loss. We routinely use the best-fit circle method drawn at the inferior two-thirds of the glenoid as described earlier. This calculation is included with the method described by Itoi et al.16 to determine the amount of residual glenoid bone compared with the Hill-Sachs interval. If the Hill-Sachs interval is larger than the glenoid track, the Hill-Sachs lesion is off track or engaging.
It is well known that Hill-Sachs lesions contribute to recurrent dislocations. The concept of engaging versus non-engaging lesions of Burkhart and De Beer1 and the concept of the “glenoid track” of Itoi et al.16 helped identify when these lesions must be addressed.14, 15, 17 The importance of these complementary concepts is that they both evaluate the interaction of bipolar bone loss (on the glenoid side and humeral side, i.e., Hill-Sachs). Burkhart and De Beer defined a significant bone defect to be an engaging Hill-Sachs lesion if it was oriented in such a way that it engaged the anterior glenoid in a position of athletic function (90° of abduction/90° of external rotation). They found that instabilities associated with engaging-type Hill-Sachs lesions were at high risk of recurrence if treated with the classic arthroscopic labral repair, confirming that the restoration of the soft tissues alone would not be sufficient to contain the humeral head under these conditions. This concept was merged with the on-track/off-track idea through the collaboration of Di Giacomo et al.18
We routinely use the perfect-circle method to calculate bone loss. When we measured the Hill-Sachs interval, it was found to exceed the margins of the intact glenoid, hence qualifying as an off-track or engaging lesion. Treating the labral pathology or anterior bone loss alone would likely lead to recurrent dislocations, hence the addition of a remplissage. Our general guidelines for managing bipolar lesions are in line with those described by Provencher et al.19 (Table 2). If glenoid bone loss is less than 25% with an on-track Hill-Sachs lesion, arthroscopic Bankart repair is capable of reliable outcomes. Glenoid bone defects of less than 25% with an off-track Hill-Sachs lesion, however, should receive an arthroscopic Bankart repair in addition to a remplissage. Glenoid defects of 25% or greater with an on-track Hill-Sachs lesion should undergo a Latarjet procedure, and in cases of glenoid bone loss of 25% or greater and an off-track Hill-Sachs lesion, we recommend performing a Latarjet procedure and addressing the Hill-Sachs lesion (remplissage, bone grafting, or resurfacing the defect). The latter scenario of a Hill-Sachs lesion continuing to engage after a Latarjet procedure is exceedingly uncommon. In conclusion, determining the amount of glenoid bone loss and degree to which a Hill-Sachs lesion contributes to instability will allow surgeons to choose the appropriate technique and decrease the risk of recurrence.
Table 2.
Guidelines for Managing Bipolar Lesions
| % Bone Loss | Hill-Sachs Lesion | Procedure |
|---|---|---|
| <25% | On track | Arthroscopic Bankart repair |
| <25% | Off track or engaging | Arthroscopic Bankart repair plus remplissage |
| ≥25% | On track | Latarjet |
| ≥25% | Off track or engaging∗ | Latarjet and addressing of Hill-Sachs lesion (remplissage, bone grafting, or resurfacing defect) |
If the Hill-Sachs lesion engages after a Latarjet procedure is performed, the Hill-Sachs lesion should be addressed.
Footnotes
The authors report the following potential conflict of interest or source of funding: J.M.T. receives support from Arthrex, DePuy, Mitek.
Supplementary Data
Arthroscopic repair of a panlabral lesion demonstrating optimal placement of an anterior superior portal, anterior-medial portal and percutaneous posterior inferior portal for labral mobilization and anchor placement from a lateral decubitus position. After repair of the labrum, we detail proper preparation and anchor placement in the Hill-Sachs lesion and our remplissage technique utilizing a double-pulley technique.
References
- 1.Burkhart S.S., De Beer J.F. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16:677–694. doi: 10.1053/jars.2000.17715. [DOI] [PubMed] [Google Scholar]
- 2.Boileau P., Villalba M., Hery 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]
- 3.Shaha J.S., Cook J.B., Song D.J. Redefining “critical” bone loss in shoulder instability: Functional outcomes worsen with “subcritical” bone loss. Am J Sports Med. 2015;43:1719–1725. doi: 10.1177/0363546515578250. [DOI] [PubMed] [Google Scholar]
- 4.Huijsmans P.E., Haen P.S., Kidd M., Dhert W.J., van der Hulst V.P., Willems W.J. Quantification of a glenoid defect with three-dimensional computed tomography and magnetic resonance imaging: A cadaveric study. J Shoulder Elbow Surg. 2007;16:803–809. doi: 10.1016/j.jse.2007.02.115. [DOI] [PubMed] [Google Scholar]
- 5.Huysmans P.E., Haen P.S., Kidd M., Dhert W.J., Willems J.W. The shape of the inferior part of the glenoid: A cadaveric study. J Shoulder Elbow Surg. 2006;15:759–763. doi: 10.1016/j.jse.2005.09.001. [DOI] [PubMed] [Google Scholar]
- 6.Hubbell J.D., Ahmad S., Bezenoff L.S., Fond J., Pettrone F.A. Comparison of shoulder stabilization using arthroscopic transglenoid sutures versus open capsulolabral repairs: A 5-year minimum follow-up. Am J Sports Med. 2004;32:650–654. doi: 10.1177/0095399703258747. [DOI] [PubMed] [Google Scholar]
- 7.Kartus J., Kartus C., Povacz P., Forstner R., Ejerhed L., Resch H. Unbiased evaluation of the arthroscopic extra-articular technique for Bankart repair: A clinical and radiographic study with a 2- to 5-year follow-up. Knee Surg Sports Traumatol Arthrosc. 2001;9:109–115. doi: 10.1007/s001670000180. [DOI] [PubMed] [Google Scholar]
- 8.Fabbriciani C., Milano G., Demontis A., Fadda S., Ziranu F., Mulas P.D. Arthroscopic versus open treatment of Bankart lesion of the shoulder: A prospective randomized study. Arthroscopy. 2004;20:456–462. doi: 10.1016/j.arthro.2004.03.001. [DOI] [PubMed] [Google Scholar]
- 9.Phadnis J., Arnold C., Elmorsy A., Flannery M. Utility of the Instability Severity Index Score in predicting failure after arthroscopic anterior stabilization of the shoulder. Am J Sports Med. 2015;43:1983–1988. doi: 10.1177/0363546515587083. [DOI] [PubMed] [Google Scholar]
- 10.Harris J.D., Gupta A.K., Mall N.A. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy. 2013;29:920–933. doi: 10.1016/j.arthro.2012.11.010. [DOI] [PubMed] [Google Scholar]
- 11.Hobby J., Griffin D., Dunbar M., Boileau P. Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations. J Bone Joint Surg Br. 2007;89:1188–1196. doi: 10.1302/0301-620X.89B9.18467. [DOI] [PubMed] [Google Scholar]
- 12.Wolf E.M., Arianjam A. Hill-Sachs remplissage, an arthroscopic solution for the engaging Hill-Sachs lesion: 2- to 10-year follow-up and incidence of recurrence. J Shoulder Elbow Surg. 2014;23:814–820. doi: 10.1016/j.jse.2013.09.009. [DOI] [PubMed] [Google Scholar]
- 13.Koo S.S., Burkhart S.S., Ochoa E. Arthroscopic double-pulley remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs. Arthroscopy. 2009;25:1343–1348. doi: 10.1016/j.arthro.2009.06.011. [DOI] [PubMed] [Google Scholar]
- 14.Aigner F., Longato S., Fritsch H., Kralinger F. Anatomical considerations regarding the “bare spot” of the glenoid cavity. Surg Radiol Anat. 2004;26:308–311. doi: 10.1007/s00276-003-0217-8. [DOI] [PubMed] [Google Scholar]
- 15.Kralinger F., Aigner F., Longato S., Rieger M., Wambacher M. Is the bare spot a consistent landmark for shoulder arthroscopy? A study of 20 embalmed glenoids with 3-dimensional computed tomographic reconstruction. Arthroscopy. 2006;22:428–432. doi: 10.1016/j.arthro.2005.12.006. [DOI] [PubMed] [Google Scholar]
- 16.Itoi E., Yamamoto N., Kurokawa D., Sano H. Bone loss in anterior instability. Curr Rev Musculoskelet Med. 2013;6:88–94. doi: 10.1007/s12178-012-9154-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Burkhart S.S., Debeer J.F., Tehrany A.M., Parten P.M. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy. 2002;18:488–491. doi: 10.1053/jars.2002.32212. [DOI] [PubMed] [Google Scholar]
- 18.Di Giacomo G., Itoi E., Burkhart S.S. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: From “engaging/non-engaging” lesion to “on-track/off-track” lesion. Arthroscopy. 2014;30:90–98. doi: 10.1016/j.arthro.2013.10.004. [DOI] [PubMed] [Google Scholar]
- 19.Provencher M.T., Bhatia S., Ghodadra N.S. Recurrent shoulder instability: current concepts for evaluation and management of glenoid bone loss. J Bone Joint Surg Am. 2010;92(suppl 2):133–151. doi: 10.2106/JBJS.J.00906. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Arthroscopic repair of a panlabral lesion demonstrating optimal placement of an anterior superior portal, anterior-medial portal and percutaneous posterior inferior portal for labral mobilization and anchor placement from a lateral decubitus position. After repair of the labrum, we detail proper preparation and anchor placement in the Hill-Sachs lesion and our remplissage technique utilizing a double-pulley technique.