Abstract
Dynamic anterior stabilization of the shoulder is a surgical procedure based on a triple soft-tissue block. This procedure is designed to fit within a gray zone between the Bristow-Latarjet procedure and the Bankart procedure, where the patient would not need a bone graft; however, capsular reconstruction alone may be insufficient to yield reliable stabilization. This article describes dynamic anterior stabilization of the shoulder using the adjustable-loop device.
Technique Video
Dynamic anterior stabilization of shoulder with adjustable-loop device. Blunt dissection is performed using a Kelly device in the direction of the fibers of the shoulder capsule and subscapularis tendon. A bipolar radiofrequency device is used to widen this split of the capsule and subscapularis, allowing instrumentation through the anteroinferolateral portal. A 4-point 5-mm drill is inserted anteriorly by using a specific guide for dynamic anterior stabilization, and a hole is created from anterior to posterior. The blunt end of a perforated Kirschner wire is used to pass a blue nylon guidewire from anterior to posterior. The long head of the biceps (LHB) tendon is cut in a region where this tendon can move through the bicipital groove with no problems by using a thin basket inserted through the anterior portal. A nylon wire is inserted into the biceps to establish a landmark. Just proximal to the pectoralis major tendon, the LHB is found. It is pulled out of the bicipital groove by use of a regular probe. The tendon is pulled out of the body through the anteroinferolateral portal by use of an arthroscopic grasper. A Krackow suture is placed in the biceps. The nylon guidewire passes the polyester adjustable-loop device’s guide through the hole from anterior to posterior. The adjustable-loop device is carefully fixed on the posterior aspect of the scapula. A fluoroscopic examination can ensure that the adjustable-loop device is fixed on the posterior surface of the scapula. The high-resistance wire sutured in the LHB is passed through the adjustable-loop device loops. With the scope in the posterior portal, one can see this high-resistance wire through the adjustable-loop device loops. The biceps is pulled through the subscapularis split and sutured to these loops. Now, the LHB is ready to be pulled into the hole of the anterior glenoid rim. The adjustable-loop device loops will bring the LHB into the bone. All sutured part of the tendon will need to be into the bone. The adjustable-loop device wires are cut, and the LHB is transferred. A soft-tissue anchor is inserted inferior to the biceps to suture the inferior labrum. Another soft-tissue anchor is inserted to suture the superior labrum. Postoperative radiographs will confirm the position of the adjustable-loop device. The posterior and anterior portals can be visualized.
Anterior shoulder instability remains one of the main issues within shoulder surgery. There are several studies showing that arthroscopic Bankart repair is successful in treating traumatic anterior shoulder instability without bone loss.1 On the other hand, glenoid bone loss greater than 21% to 25% and engaging lesions seem to present better results when bony procedures such as the Bristow and Latarjet procedures are performed,2, 3, 4, 5 and both techniques present similar results.6 Some authors have suggested that other predictive factors—age at the first episode, sport, and so on—need to be considered when choosing the surgical procedure, whereas others have suggested that even 13.5% of glenoid bone loss can be deemed critical bone loss.1,7 Indeed, there is a gray zone in the treatment of anterior shoulder instability, which can be treated by both the Bankart and Bristow-Latarjet procedures.
Some authors have presented an arthroscopic belt-and-suspenders procedure combining principles of the Bankart and Bristow-Latarjet procedures to improve shoulder stability by using only soft-tissue stabilizers; however, this procedure is time-consuming, uses a large medial bone tunnel, and presents a recurrence rate of 8%.8 Many authors have reported that the long head of the biceps (LHB) does not have an important function related to shoulder stability. In addition, some studies have suggested that the LHB is just a vestigial structure, presenting a not suitable mechanic axis for not quadrupid animals.9, 10, 11, 12
On the basis of these fundamentals, it seems more rational to use the LHB to provide both the sling and direct block effects.13 These 2 biomechanical stabilizer mechanisms in a lateralized fashion associated with the Bankart procedure can achieve better results in the aforementioned gray zone. Indeed, some authors have described performing this procedure using interference screws14,15 and anchors.16 The adjustable-loop device is a fixation method that allows a strong fixation and biologic healing. Thus, our technique joins the idea of the triple soft-tissue block of the dynamic anterior stabilization (DAS) with a better LHB healing condition by using the adjustable-loop device.
Surgical Technique
The patient is placed in the beach-chair position under general anesthesia. Through the standard posterior portal, the articular inspection is performed, and the lesions are examined under an arthroscopic view. An anteroinferolateral portal is created 1 cm inferior and just lateral to the standard anterior portal. The best location for this portal can be confirmed with a 16-gauge needle. The portal needs to be in line with the humeral head equator. Through this portal, the subscapularis tendon is gently opened in the direction of its fibers by using a Kelly device. At this moment, an electrocautery device and/or shaver is useful to widen the subscapularis split (Fig 1). A standard anterior portal is also created, through which the surgeon performs LHB tenotomy. The anterior glenoid rim is exposed, and the bone is shaved to expose the bone marrow, allowing better healing, similar to the Bankart procedure.
Fig 1.
Split subscapularis tendon (A), with optics through posterior portal.
Thereafter, the scope is inserted into the anteroinferolateral portal. The scope moves downward in the direction of the pectoralis major insertion. Visualization of the axillary nerve is highly suggested at this point. Other instruments are inserted through the anterior portal. The optic is inserted into the anterior portal, and the LHB tendon is then pulled out just over the pectoralis major using a regular probe (Fig 2). Thereafter, the LHB is pulled out of the body through the anteroinferolateral portal by use of a grasper. If the surgeon does not release the LHB just over the pectoralis major, the LHB cannot present free motion, and the patient can lose movement after surgery.
Fig 2.
Pectoralis major tendon (A), long head of biceps (B), and humerus (C), with optics through posterior portal.
Krackow sutures are placed on the LHB by use of high-resistance #5 Maxibraid (Zimmer-Biomet, Warsaw, IN) (Fig 3). A 4.5-mm drill is inserted using the guide of the DAS FastFit Button (Razek, São Carlos, Brazil) (Figs 4 and 5) through the subscapularis split, and the size of the glenoid is measured. Its insertion point is just medial to the anterior glenoid rim at the 3- to 4-o’clock position. If the LHB diameter is superior to 4.5 mm, the surgeon can make a vertical incision on the LHB in order to reduce its diameter for this tendon's proximal 2 cm or can enlarge the hole by using a 5.5- or 6.5-mm drill for the initial 2 cm (Fig 4); sizes larger than those mentioned earlier are not recommended.
Fig 3.
(A) High-resistance wire. (B) Long head of biceps.
Fig 4.
(A) adjustable-loop device. (B) Long head of biceps. (C) High-resistance wire. (D) Terminal adjustable-loop device wires. (E) adjustable-loop device loops. (F) Drills. (G) Dynamic anterior stabilization guide : Drills: 4.5-mm drill for fastfit-Button and 2 drills to enlarge insertion hole, 5.5 mm and 6.5 mm, for wider biceps diameters.
Fig 5.
Insertion of 4.5-mm drill (A) and dynamic anterior stabilization guide (B), with optics through posterior portal glenoid (C), humeral head (D).
A perforated Kirschner wire is inserted with a No. 0 nylon wire using its blunt side from anterior to posterior to avoid nerve lesions (Fig 6). This nylon is used as a guide for the FastFit Button to be passed from anterior to posterior. The one side of the high-resistance wire inserted in the LHB passes within the loops of the FastFit Button. The FastFit Button is inserted through the subscapularis split on the anterior glenoid rim, and the LHB is sutured to the loop (Figs 7 and 8). The sutured LHB is pulled into the hole by pulling the terminal adjustable-loop device wires. This maneuver will drive and lock the loops and the sutured LHB into the hole; ideally, 2 cm within the hole is enough (Fig 9). Two 1.6-mm FastFit Anchors (Razek) are inserted above and under the LHB tendon through the subscapularis split by using a cannula in the anteroinferolateral portal, allowing the surgeon to perform labral reconstruction (Fig 10, Video 1). Pearls and pitfalls of the described procedure are presented in Table 1.
Fig 6.
Glenoid (A). No. 0 guide nylon (B). Perforated Kirschner (C). Optics through posterior portal.
Fig 7.
Glenoid (A), terminal adjustable-loop device wires (B), EndoButton loops (C), and high-resistance wire (D), with optics through posterior portal.
Fig 8.
Glenoid (A), terminal adjustable-loop device wires (B), EndoButton loops (C), high-resistance wire (D), and long head of biceps (E), with optics through posterior portal.
Fig 9.
Glenoid (A), long head of biceps (B), and humeral head (C), with optics through posterior portal.
Fig 10.
Suturing of labrum, with optics through posterior portal.
Table 1.
Pearls and Pitfalls
| Pearls and Pitfalls | |
|---|---|
| Anterolateral portal | The ideal point is 45° anterior to the scapular axis, just over the biceps deflection, guided by an 18-gauge needle in an intra-articular view, with the scope in the posterior portal. |
| Anteroinferolateral portal | The ideal point is through the subscapularis tendon, near its insertion in the humerus, in line with the humeral head equator, guided by an 18-gauge needle in an intra-articular view, with the scope in the posterior portal. |
| LHB cutting | An anteroinferolateral portal or standard anterior portal is used. Do not cut so proximal, do that where the elliptical diameters seem to be more similar to those of the LHB. |
| Assessment of superior portion of pectoralis tendon | The scope is inserted in the anteroinferolateral portal, in the subdeltoid space, in the direction of the pectoralis major insertion. The bursa is carefully shaved; the LHB emerges from the bicipital tunnel under the superior portion of the pectoralis major, beneath the short head. Special care is needed for bleeding in this region because vessels can be close. |
| Insertion point | Just drill the tunnel after the LHB tendon is pulled out. The guidewire is inserted just over the LHB, through the subscapularis split, with no cannula. The guidewire is inserted just medial to the glenoid rim at the 3-o’clock position, similar to anchor insertion. The hole can extend to the glenoid. A cannula is not used. |
| Guide | The guide is inserted just medial to the glenoid rim at the 3-o’clock position flush with the articulation, similar to anchor insertion. A cannula is not used in this moment. |
| Tunnel diameter | The diameter needs to be the same size as the LHB tendon. More suitable diameters can be chosen according the biceps diameter. |
| Anchor insertion | Once the space is small, preference should be given to soft-tissue anchors. A cannula is used through the regular anterior portal as in regular Bankart reconstruction to access the labrum. |
LHB, long head of biceps.
Discussion
The sling effect is the main stabilizer of the shoulder in the Bristow and Latarjet procedures. It is responsible for 51% to 77% of the shoulder stabilization, depending on the upper-limb position.13 DAS of the shoulder provides the same soft-tissue benefits as the Bristow and Latarjet procedures associated with labral reconstruction in the Bankart procedure, presenting a triple soft-tissue block.
The key goals achieved using the described procedure are tension to the inferior part of the subscapularis during abduction and external rotation, a direct block effect of the LHB in its new position, and labral reconstruction. This procedure changes the shoulder kinematics similar to the Latarjet procedure but with no bone block.17 Some biomechanical studies have shown that at end-range position for abduction and external rotation of the shoulder the capsule, conjoined tendon's direct block and the sling effect can be the only responsible for the stability on the Latarjet procedure.13
A similar triple soft-tissue block was described using the conjoined tendon8 instead of the LHB. However, because of the large transverse area of the conjoined tendon, the interference screw needs to have a greater diameter, as does its introduction hole.
In other procedures involving the LHB, interference screws were used for fixation; however, some drawbacks of using interference screws are possible osteolysis and a smaller tendon–bone marrow contact area.18, 19, 20 Prior studies have used suture anchors16; however, suture anchors will present with inferior load to failure compared with the adjustable-loop device for many applications, and it is rational to think the same way about DAS. In addition, anchors are less predictable for changing LHB tendon tension. Insertion of 20 mm of the LHB tendon within the bone is desirable to keep its suitable tension.15 Table 2 presents a comparison between fixation methods.
Table 2.
Comparison Between Fixation Methods
| DAS Fixation |
|||
|---|---|---|---|
| Interference Screw | Anchor | Adjustable-loop device | |
| Intraoperative complications | Fracture of anterior glenoid, loosening of fixation of interference screw | Lower bicipital tension, Popeye deformity | Possible neurologic lesion if surgeon does not drill hole parallel to glenoid equator |
| Postoperative complications | Osteolysis | None | None |
| Fixation | Strong | Intermediate | Strong |
| Biological integration | Intermediate | Intermediate | Better |
DAS, dynamic anterior stabilization.
For Bristow procedures medialization of the graft can increase recurrence rates of shoulder instability. Once DAS presents a similar biomechanic of Bristow procedure a more lateral position for insertion of the LHB, as suggested on this paper, will allow better shoulder stability.21
There is no consensus on the role of the dynamic stabilizers of the shoulder. Thus far, all biomechanical studies using cadavers have rendered ineffective dynamic assessments. Labral proprioception can also play an important and neglected role in shoulder stability.22 We suggest that the described procedure and similar procedures14, 15, 16,23 will add not just biomechanical stabilization24 but also tendon proprioception of the LHB; moreover, the subscapularis split can play an important role in shoulder stabilization.
Some authors have described a similar technique but with different, more demanding surgical steps and no attachment of the labrum.23 Reattaching the labrum is essential to our technique, and proprioception is one of the pillars behind the success of this technique; no preservation of the labrum and capsule can result in higher redislocation rates.22
Similarly to other authors, we believe that the LHB is a residual structure derived from the ancient coracoid bone in quadrupeds.12,25 In bipeds, this bone also followed the natural axis of the biceps originating from the coracoid process with 90° rotation of the original coracoid bone.12,25 Some primates do not present an LHB similar to that in humans, whereas in some, the LHB can even originate on the pectoralis major insertion or in the humeral head.26,27 Indeed, the real kinematic importance of the LHB is still controversial.
The described procedure will not substitute for bone block procedures when more than 20% of glenoid bone loss is present; instead, it will add more stability to the current soft-tissue procedures in the presence of smaller amounts of bone loss. It could also be useful in athletes and high-demand patients.1,4,7 Advantages and disadvantages of this procedure compared with other DAS procedures are presented in Table 2.
When performing the described procedure, it is possible to incorporate other procedures, such as remplissage. In addition, in case of failure of this procedure, it is possible to apply the Bristow or Latarjet procedure. There is a possibility of LHB tendon rupture, glenoid fracture, and cyst formation, although we have never observed these conditions. The surgical time to access the superior insertion of the pectoralis major is longer with this procedure than with the Bankart procedure, as is arthroscopic training. If the LHB is pathologic and presents areas of disruption, it can also be oversized in its intra-articular portion. In this case, opening the intertubercular ligament can be an option to release the LHB. In our opinion, this surgical procedure and similar procedures15,23 can fit exactly in the gray zone between the Bankart and Bristow-Latarjet procedures.25
Footnotes
The authors report the following potential conflicts of interest or sources of funding: J.C.G. is a consultant for Zimmer-Biomet Latin America and receives royalties for developing orthopaedic devices from Razek, outside the submitted work. M.d.P.R. is a consultant for Implantcast, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
Dynamic anterior stabilization of shoulder with adjustable-loop device. Blunt dissection is performed using a Kelly device in the direction of the fibers of the shoulder capsule and subscapularis tendon. A bipolar radiofrequency device is used to widen this split of the capsule and subscapularis, allowing instrumentation through the anteroinferolateral portal. A 4-point 5-mm drill is inserted anteriorly by using a specific guide for dynamic anterior stabilization, and a hole is created from anterior to posterior. The blunt end of a perforated Kirschner wire is used to pass a blue nylon guidewire from anterior to posterior. The long head of the biceps (LHB) tendon is cut in a region where this tendon can move through the bicipital groove with no problems by using a thin basket inserted through the anterior portal. A nylon wire is inserted into the biceps to establish a landmark. Just proximal to the pectoralis major tendon, the LHB is found. It is pulled out of the bicipital groove by use of a regular probe. The tendon is pulled out of the body through the anteroinferolateral portal by use of an arthroscopic grasper. A Krackow suture is placed in the biceps. The nylon guidewire passes the polyester adjustable-loop device’s guide through the hole from anterior to posterior. The adjustable-loop device is carefully fixed on the posterior aspect of the scapula. A fluoroscopic examination can ensure that the adjustable-loop device is fixed on the posterior surface of the scapula. The high-resistance wire sutured in the LHB is passed through the adjustable-loop device loops. With the scope in the posterior portal, one can see this high-resistance wire through the adjustable-loop device loops. The biceps is pulled through the subscapularis split by these sutured loops. Now, the LHB is ready to be pulled into the hole of the anterior glenoid rim. The adjustable-loop device loops will bring the LHB into the bone. The part of the tendon that underwent Krackow sutures needs to be within the bone. The adjustable-loop device wires are cut, and the LHB is transferred. A soft-tissue anchor is inserted inferior to the biceps to suture the inferior labrum. Another soft-tissue anchor is inserted to suture the superior labrum. Postoperative radiographs will confirm the position of the adjustable-loop device. The posterior and anterior portals can be visualized.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Dynamic anterior stabilization of shoulder with adjustable-loop device. Blunt dissection is performed using a Kelly device in the direction of the fibers of the shoulder capsule and subscapularis tendon. A bipolar radiofrequency device is used to widen this split of the capsule and subscapularis, allowing instrumentation through the anteroinferolateral portal. A 4-point 5-mm drill is inserted anteriorly by using a specific guide for dynamic anterior stabilization, and a hole is created from anterior to posterior. The blunt end of a perforated Kirschner wire is used to pass a blue nylon guidewire from anterior to posterior. The long head of the biceps (LHB) tendon is cut in a region where this tendon can move through the bicipital groove with no problems by using a thin basket inserted through the anterior portal. A nylon wire is inserted into the biceps to establish a landmark. Just proximal to the pectoralis major tendon, the LHB is found. It is pulled out of the bicipital groove by use of a regular probe. The tendon is pulled out of the body through the anteroinferolateral portal by use of an arthroscopic grasper. A Krackow suture is placed in the biceps. The nylon guidewire passes the polyester adjustable-loop device’s guide through the hole from anterior to posterior. The adjustable-loop device is carefully fixed on the posterior aspect of the scapula. A fluoroscopic examination can ensure that the adjustable-loop device is fixed on the posterior surface of the scapula. The high-resistance wire sutured in the LHB is passed through the adjustable-loop device loops. With the scope in the posterior portal, one can see this high-resistance wire through the adjustable-loop device loops. The biceps is pulled through the subscapularis split and sutured to these loops. Now, the LHB is ready to be pulled into the hole of the anterior glenoid rim. The adjustable-loop device loops will bring the LHB into the bone. All sutured part of the tendon will need to be into the bone. The adjustable-loop device wires are cut, and the LHB is transferred. A soft-tissue anchor is inserted inferior to the biceps to suture the inferior labrum. Another soft-tissue anchor is inserted to suture the superior labrum. Postoperative radiographs will confirm the position of the adjustable-loop device. The posterior and anterior portals can be visualized.
Dynamic anterior stabilization of shoulder with adjustable-loop device. Blunt dissection is performed using a Kelly device in the direction of the fibers of the shoulder capsule and subscapularis tendon. A bipolar radiofrequency device is used to widen this split of the capsule and subscapularis, allowing instrumentation through the anteroinferolateral portal. A 4-point 5-mm drill is inserted anteriorly by using a specific guide for dynamic anterior stabilization, and a hole is created from anterior to posterior. The blunt end of a perforated Kirschner wire is used to pass a blue nylon guidewire from anterior to posterior. The long head of the biceps (LHB) tendon is cut in a region where this tendon can move through the bicipital groove with no problems by using a thin basket inserted through the anterior portal. A nylon wire is inserted into the biceps to establish a landmark. Just proximal to the pectoralis major tendon, the LHB is found. It is pulled out of the bicipital groove by use of a regular probe. The tendon is pulled out of the body through the anteroinferolateral portal by use of an arthroscopic grasper. A Krackow suture is placed in the biceps. The nylon guidewire passes the polyester adjustable-loop device’s guide through the hole from anterior to posterior. The adjustable-loop device is carefully fixed on the posterior aspect of the scapula. A fluoroscopic examination can ensure that the adjustable-loop device is fixed on the posterior surface of the scapula. The high-resistance wire sutured in the LHB is passed through the adjustable-loop device loops. With the scope in the posterior portal, one can see this high-resistance wire through the adjustable-loop device loops. The biceps is pulled through the subscapularis split by these sutured loops. Now, the LHB is ready to be pulled into the hole of the anterior glenoid rim. The adjustable-loop device loops will bring the LHB into the bone. The part of the tendon that underwent Krackow sutures needs to be within the bone. The adjustable-loop device wires are cut, and the LHB is transferred. A soft-tissue anchor is inserted inferior to the biceps to suture the inferior labrum. Another soft-tissue anchor is inserted to suture the superior labrum. Postoperative radiographs will confirm the position of the adjustable-loop device. The posterior and anterior portals can be visualized.