Dear Editor,
I read with interest the article entitled “Single anterior portal: A better option for arthroscopic treatment of traumatic anterior shoulder instability?” by Çiçek et al. published online.1 I congratulate the authors for the interesting study and the results obtained. The authors concluded that single anterior portal technique for patients undergoing surgery for arthroscopic repair of Bankart lesion is more cost-effective and requires less postoperative analgesia compared to patients operated with two anterior portals. Also, the study showed no significant differences between the 2 techniques with respect to clinical results or complication rates. I agree with the main idea resulting from the study, meaning that if one can obtain the same result by a less invasive technique than maybe it’s better for our patients. However I would recommend caution using routinely only one anterior portal for arthroscopic anterior shoulder stabilization. The problem arises from using only the posterior portal as a viewing portal. An additional antero-superior portal, mainly for viewing purposes is very important due to the following:
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1.
Glenoid bone loss is an important risk factor for failure after arthroscopic Bankart repair.2,3 During gleno-humeral arthroscopy, assessment for bone loss on the glenoid side is done while viewing from the antero-superior portal.4
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2.
The entire anterior structures and pathology is better evaluated while viewing through the antero-superior portal as compared to the view obtained from the posterior portal. The release of the scared labrum and capsule and the preparation of the medial glenoid bone is a crucial step of the procedure. This part is also better evaluated with the scope in the antero-superior portal. Fig. 1 and Fig. 2 show the difference in view of the anterior structures.
Fig. 1.
Intra-articular view of the left shoulder. The scope is in the posterior portal. Lateral decubitus position. HH - humeral head. G - Glenoid.
Fig. 2.
Intra-articular view of the left shoulder. The scope is in the antero-superior portal. Lateral decubitus position. HH - humeral head. G - Glenoid.
I again congratulate the authors and appreciate their experience. I also suggest that using an additional antero-superior portal for viewing during anterior Bankart repair can help the surgeon avoid some technical errors and the potential risks of not using this additional portal may outweigh the benefits.
Author's response:
Dear Editor,
We would like to respond to some of the queries that has been raised related to the technique in our study, ‘Single anterior portal: a better option for arthroscopic treatment of traumatic anterior shoulder instability?’.
The visual field of the anterior compartment obtained from the posterior portal is sufficient for the identification or intervention of most pathologies, as shown in the comment. However, we always prefer to move the scope to anterior portal before and after releasing the labrum to visualize the glenoid rim or Perthes and ALPSA lesions. Anterior visualization is also important to confirm the liberation of labrum till the Subscapularis muscle fibers can be seen. We do not prefer to work using two anterior portals simultaneously.
In summary we agree the importance of anterior portal visualization for anterior glenoid rim and injured labrum, however this can easily be performed via standard posterior and single anterior portals, too.
Footnotes
Peer review under responsibility of Turkish Association of Orthopaedics and Traumatology.
References
- 1.Çiçek H., Tuhanioglu Ü., Ogur H.U., Seyfettinoglu F., Çiloglu O., Beyzadeoglu T. Single anterior portal: A better option for arthroscopic treatment of traumatic anterior shoulder instability? Acta Orthop Traumatol Turc. 2017;4:298–302. doi: 10.1016/j.aott.2017.03.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
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