Anterosuperior Portal Research Articles

Anterior Labrum Periosteal Sleeve Avulsion Lesions of the Shoulder: A Scoping Review.

Anterior labrum periosteal sleeve avulsion (ALPSA) lesion of the shoulder is defined as a labral avulsion with an intact periosteum of the glenoid neck resulting in medial malattachment of the labrum, which is both nonanatomic and nonfunctional. It is relatively rare compared with Bankart lesions, and its results are usually reported in combination with other anterior labroligamentous lesions in the literature. To (1) assess the size and scope of the literature on ALPSA lesions, (2) highlight the importance of this lesion, and (3) distinguish between ALPSA and Bankart lesions in diagnostic and treatment strategies. Scoping review; Level of evidence, 4. The PubMed, Scopus, Embase, and Google Scholar databases were searched with the keywords "ALPSA,""anterior labrum periosteal sleeve avulsion,""anterior labral periosteal sleeve avulsion," and "anterior labroligamentous periosteal sleeve avulsion" lesion. Duplicate articles and those that did not meet the inclusion criteria were excluded, resulting in the identification of 42 relevant articles. Their references were analyzed for further data curation. This scoping review demonstrated that ALPSA lesions are difficult to clinically identify. Magnetic resonance angiography in the adduction internal rotation position is the most sensitive and specific imaging modality for identification. Optimal views are the anterosuperior portal for accurate identification and the anteroinferior portal for surgical repair during arthroscopy. Treatment begins with correctly identifying the labrum, in contradistinction to dense reactive fibrous tissue, and reattaching the labrum to the correct anatomic glenoid footprint. Chronic lesions with bone loss require either bone block or soft tissue augmentation procedures. There is paucity of exclusive literature on ALPSA lesions. It is important to distinguish this lesion from the Bankart lesion as it is associated with worse outcomes. The higher failure rates of ALPSA lesion repair indicate that the current repair techniques require further refinement to improve the outcomes to the standard of Bankart lesions.

Arthroscopic Remplissage Using a Double-Pulley Technique

Background: Anterior shoulder instability is associated with Hill-Sachs lesions (HSLs) in 40% to 90% of cases. When addressing anterior shoulder instability, unaddressed engaging or “off-track” HSL have a recurrence rate of 75%. Remplissage is a known technique to address recurrent instability in the setting of an engaging HSL. In this video, we demonstrate that a double-anchor-pulley technique may be used to address recurrent instability in the setting of engaging HSL. Indications: Patients with recurrent anterior shoulder instability with off-track HSL in patients with glenoid bone loss <20% are candidates for arthroscopic Remplissage. Technique Description: Patients are placed in the lateral decubitus position. Examination under anesthesia is performed to assess for degree of instability and engagement of HSL. Posterior, anterosuperior, and anteroinferior portals are established. Routine diagnostic arthroscopy is performed with identification of the HSL. While viewing from an anterosuperior portal and working through the posterior portal, the HSL bed is prepared with curettage and a bur. A 5.5-mm accessory Cannula is used through an accessory posterior portal. Two knotless all-suture self-tensioning anchors are placed in the anterior and inferior aspect of the defect, passed through the cannula, and tagged for later identification. Bankart stabilization is performed. The knotless anchors are linked to each other to perform a knotless repair with a broad area of compression. Results: Results are excellent with only a 5.6% failure rate, significant patient improvement, low complication rate, and 95.5% return to play. Discussion: We demonstrate the technical aspects of an all-arthroscopic Remplissage technique using all-suture knotless anchors to provide a simple and reproducible method of performing a Remplissage. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Remplissage for Anterior Shoulder Instability

Background: There are several approaches such as the Bankart repair, Latarjet, and Remplissage to treat recurrent glenohumeral instability. Indications: We chose to augment an arthroscopic Bankart repair with a Remplissage in this 26-year-old patient given the presence of a Hill-Sachs lesion, history of recurrent shoulder dislocations, and young age of the patient. Technique Description: We established four portals using previously well-documented techniques. The Hill-Sachs lesion was evaluated using the anterosuperior portal. Two anchors were placed, one on both the superior and inferior aspects of the Hill-Sachs lesion. The sutures were shuttled through the knotless anchor mechanism and tensioned after confirming the cannula was through the deltoid. Then, we completed the Remplissage by repairing the infraspinatus tendon and capsule into the posterior humeral head. Results: The Remplissage procedure is very successful at reducing recurrent instability in young, active patients. Previous studies have reported very low rates, even 0% recurrent instability, after surgery with 80% to 90% of patients returning to sports. Studies have also documented excellent patient-reported outcomes at short- to mid-term follow-up. Complication rates are historically lower when the Remplissage is done with an arthroscopic Bankart repair than the Bankart repair alone. Discussion/Conclusion: The Remplissage procedure is a safe, effective option at reducing future instances of shoulder dislocations in conjunction with Bankart repairs. Patients can expect to return to their active lifestyles, with many patients achieving the same level of activity as before the initial shoulder dislocation. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Metal-Free Fixation for Free Bone-Block Reconstruction of Chronic Anteroinferior Shoulder Instability

Background: Anterior shoulder instability is common and may cause a considerable effect on quality of life. For cases with glenoid bone loss, there is still a controversial discussion regarding the optimal treatment. Most of the recent methods are using metal implants to attach the needed graft to the glenoid with reported disadvantages such as metal impingement, damage to the humeral head, cartilage destruction, and premature arthritis. Indications: (1) Erosion-type defects with significant bone loss (>15%-20%); (2) chronic fragment-type defects if the size of the fragment is not large enough for an anatomical reconstruction; and (3) non-reconstructible, multifragmented acute fragment type of lesions. Technique Description: After placing the patient in a lateral decubitus position and fixing the arm in a traction devise, 3 arthroscopic entries are established: a posterior portal, an anterosuperior portal, and an anteroinferior portal. A harvested tricortical iliac crest bone graft is provided with 2 drilling holes which match the drilling holes through the glenoid. The tapes are then placed from the posterior to the anterior side of the glenoid, and then the graft is passed from the anterior to the posterior side, thus compressing the cancellous side of the bone block onto the glenoid defect. A following interconnection of the sutures creates a continuous loop. The end of the tapes was loaded into a pretied racking hitch knot system, which creates sliding knots between the 2 pair of tapes, whereon the knots can be reduced to the glenoid in a symmetrical fashion. Finally, the reconstruction of the anterosuperior labrum can be done, to cover the bone block with enough soft tissue. Results: First short-term results show radiographic consolidation after 3 months and an increased median glenoid estimated surface area at 12 months. The functional scores showed good outcomes, and there were no serious complications reported. Discussion/Conclusion: The presented arthroscopic reconstruction of the glenoid using a tricortical bone graft and high-strength fiber tapes provides a metal-free technique which results in a high primary stability of the construct and should therefore be considered when treating anterior shoulder instability with significant bone loss.

All-Arthroscopic Treatment of Glenoid Rim Fractures

We describe an arthroscopic technique for the management of glenoid rim fractures. It is performed with the patient placed in lateral decubitus position. The fracture is assessed through the anterosuperior portal, and the fragment is mobilized. A special glenoid guide is used from the posterior portal to reduce the fragment and to create 2 tunnels through the glenoid and through the glenoid rim fragment. Two pairs of round buttons are connected with high-strength sutures and are tightened posteriorly. This allows strong fixation of the fractured fragment and avoids all the anterior structures since all the instruments are inserted posteriorly.

Arthroscopic Treatment of First-Time Shoulder Dislocations in Younger Athletes.

Background:The glenohumeral joint is characterized by its large degree of movement and consequently is the most susceptible joint to dislocations. There are few studies on the first episode of a shoulder dislocation in younger athletes.Purpose:To report the results of arthroscopic treatment for the first episode of a glenohumeral dislocation in younger athletes.Study Design:Case series; Level of evidence, 4.Methods:In this retrospective study, 53 patients younger than 40 years (N = 54 shoulders) sustained their first anterior shoulder dislocation and underwent arthroscopic surgery. Surgery was undertaken in the lateral decubitus position. Standard posterior, anteroinferior, and anterosuperior portals were used, and the number of anchors and the degree of capsular plication were individualized and based on the arthroscopic findings of each patient. The minimum follow-up was 2 years (mean, 2.31 years), and patients were evaluated with the Rowe functional score, Athletic Shoulder Outcome Rating Scale (EROE; acronym in Portuguese), and visual analog scale (VAS) for pain.Results:The mean EROE score was 93.8, with 98% of results being good or excellent, and the mean Rowe score was 95.0, with 98% good or excellent results. The mean VAS pain score was <1.0. The rate of recurrence of dislocations was 2%. The return-to-sports rate was 83%; patients with associated superior labral anterior-posterior (SLAP) lesions had a lower return-to-sports rate (P = .001) and lower EROE (P = .017) and Rowe (P = .019) scores.Conclusion:The present study showed favorable results for arthroscopic surgical treatment after the first dislocation episode in young athletes. It was an effective and safe treatment option in this population.

Advantages of Scorpion Suture Passer and 70 Degrees Arthroscope in Arthroscopic Bankart Repair: Usefulness for Inferior Labral Repair

BACKGROUND: The blunted tip of a reusable with multiple uses can cause problems with the passing procedure in arthroscopic Bankart repair. This study assessed the advantage of Scorpion with a 70° arthroscope in arthroscopic Bankart repair compared to hook typed suture passer.METHODS: Scorpion in 19 patients, the hook type suture passer (conventional group) in 18 patients were used. All patients underwent the same procedure except for the type of suture passer used. Another different point of the procedure were telescopes and the number of portals used; three arthroscopic portals (posterior, anterorsuperiorlateral, and mid-anterior) and a 30° arthroscope in the conventional group, but two portals and a 70° arthroscope as well as the 30° one in the Scorpion group. The surgery time and the surgical complications including an iatrogenic axillary nerve injury were recorded.RESULTS: The Scorpion group showed a significant decrease in surgery time compared to the conventional group. In contrast to the conventional group, Scorpion provided an easy estimation of the exit of suture passing, no iatrogenic labral injury during the passing procedure with straight movement and the sharp tip of the knife installed. Iatrogenic supraspinatus injuries could be avoided when making an accessory anteosuperiorlateral portal due to the 70° arthroscope.CONCLUSIONS: In arthroscopic Bankart repair, the use of the Scorpion suture passer and a 70° arthroscope can reduce the surgery time, avoid unnecessary supraspinatus injury, and avoid iatrogenic axillary nerve damage through the relatively easy and precise suture passing and saving of the anterosuperior portal.

Aquarium Portal Technique for PASTA Lesion Repair

The simultaneous arthroscopic exposure of the subacromial and intra-articular space of the shoulder is challenging in the presence of only partial-thickness rotator cuff tears. We present our experience and method of entering the joint through the opened rotator cuff interval from an anterosuperior portal between the coracoid process and anterior acromion. With moderate (approximately 30°) abduction and external rotation, the rotator interval opens readily, offering a view with the camera toward the anterior edge of the supraspinatus tendon. An anterior view on the anterior leading edge of the supraspinatus tendon is obtained, showing the subacromial space above and the glenohumeral space below the tendon, similar to the view in an aquarium. The rotator cuff can be elevated using a rod inserted intra-articularly from posterior, whereas anchors and other instruments may be inserted from lateral. This approach offers the advantages of full exposure of the posterior undersurface of the rotator cuff insertion; a convenient approximately 90° angle between the camera and instruments; and no need to change portals for anchor placement, tendon stitching, or suture handling. The objective of this Technical Note is to describe our arthroscopic repair approach (aquarium technique) to PASTA (partial articular supraspinatus tendon avulsion) lesions.

Shoulder Arthroscopy Does Not Adequately Visualize Pathology of the Long Head of Biceps Tendon.

Background:Pulling the long head of the biceps tendon into the joint at arthroscopy is a common method for evaluation of tendinopathic lesions. However, the rate of missed diagnoses when using this technique is reported to be as high as 30% to 50%.Hypothesis:Tendon excursion achieved using a standard arthroscopic probe does not allow adequate visualization of extra-articular sites of predilection of tendinopathy.Study Design:Descriptive laboratory study.Methods:Seven forequarter amputation cadaveric specimens were evaluated. The biceps tendon was tagged to mark the intra-articular length and the maximum excursions achieved using a probe and a grasper in both beach-chair and lateral positions. Statistical analyses were performed using analysis of variance to compare means.Results:The mean intra-articular and extra-articular lengths of the tendons were 23.9 and 82.3 mm, respectively. The length of tendon that could be visualized by pulling it into the joint with a probe through the anterior midglenoid portal was not significantly different when using either lateral decubitus (mean ± SD, 29.9 ± 3.89 mm; 95% CI, 25.7-34 mm) or beach-chair positions (32.7 ± 4.23 mm; 95% CI, 28.6-36.8 mm). The maximum length of the overall tendon visualized in any specimen using a standard technique was 37 mm. Although there was a trend to greater excursion using a grasper through the same portal, this was not statistically significant. However, using a grasper through the anterosuperior portal gave a significantly greater mean excursion than any other technique (46.7 ± 4.31 mm; 95% CI, 42.6-50.8 mm), but this still failed to allow evaluation of Denard zone C.Conclusion:Pulling the tendon into the joint with a probe via an anterior portal does not allow visualization of distal sites of predilection of pathology. Surgeons should be aware that this technique is inadequate and can result in missed diagnoses.Clinical Relevance:This study demonstrates that glenohumeral arthroscopy does not allow visualization of common areas of pathology of the long head of the biceps tendon.

Injury to the Suprascapular Nerve During Superior Labrum Anterior and Posterior Repair: Is a Rotator Interval Portal Safer Than an Anterosuperior Portal?

The purpose of this study was to compare the risk of injury to the suprascapular nerve during suture anchor placement in the glenoid when using an anterosuperior portal versus a rotator interval portal. Ten bilateral fresh human cadaveric shoulders were randomized to anchor placement through the anterosuperior portal on one shoulder and the rotator interval portal on the contralateral shoulder. Standard 3 × 14 mm suture anchors were placed in the glenoid rim (1 o'clock, 11 o'clock, and 10 o'clock positions for the right shoulder). The suprascapular nerve was dissected. When glenoid perforation occurred, the distance from the anchor tip to the suprascapular nerve, the distance from the glenoid rim to the suprascapular nerve, and the drill-hole depth at each entry site were recorded. All far-posterior anchors perforated the glenoid rim when using the anterosuperior or rotator interval portal. The distance from the far-posterior anchor tip to the suprascapular nerve averaged 8 mm (range, 3.4 to 14 mm) for the anterosuperior portal and 2.1 mm (range, 0 to 5.5 mm) for the rotator interval portal (P ≤ .001). Using an anterosuperior or rotator interval portal results in consistent penetration of 1 o'clock and 2 o'clock posterior anchors and might place the suprascapular nerve at risk of iatrogenic injury. Based on closer proximity of the anchor tip to the suprascapular nerve, the risk of injury is significantly greater with a rotator interval portal. Using a rotator interval portal for suture anchor placement in the posterior aspect of the glenoid rim can lead to a higher likelihood of suprascapular nerve injury.

Injury to the Suprascapular Nerve in Slap Repair: A Rotator Interval Portal Is not Safer Than an Anterosuperior Portal

During SLAP repair, when perforation of the glenoid occurred, 1 o’clock and 2 o’clock posterior suture anchors placed through the rotator interval portal were statistically significantly closer to the suprascapular nerve. The suprascapular nerve is potentially at risk during superior labrum repair. The Purpose of this study is to compare the risk of injury to the suprascapular nerve during suture anchor placement through an anterosuperior or rotator interval portal. Our hypothesis is that the use of the rotator interval portal provides a safer and more reproducible method than the anterosuperior portal for repair of Type II SLAP tears. Ten bilateral fresh human cadaveric shoulders were used. Each pair was randomized to suture anchor placement through an anterosuperior portal on one shoulder and a rotator interval portal, made just posterolateral to the biceps, on the contralateral shoulder. Consistent with standard SLAP repair, the suture anchors were placed into the glenoid rim at the one o’clock, eleven o’clock and ten o’clock positions for a right shoulder (eleven o’clock, one o’clock and two o’clock for a left shoulder). Drill holes were created using a 2.4mm drill with a 20mm depth stop collar. Standard 3x14mm suture anchors were placed. Following suture anchor placement, the suprascapular nerve was carefully dissected. Medial glenoid perforation was measured with digital calipers. When perforation occurred, the distance from the suture anchor tip to the suprascapular nerve was measured. The anchors were removed and the distance from the glenoid rim to the suprascapular nerve at each suture anchor entry site was recorded. A depth gage was used to measure the depth of the drill hole for each perforated anchor. All of the far posterior suture anchors (defined as the ten o’clock anchor for the right shoulder and two o’clock anchor for the left shoulder) perforated the glenoid rim using either the anterosuperior (AS) or rotator interval (RI) portal. For the far posterior anchor, the distance from the anchor tip to suprascapular nerve averaged 8.02mm (range 3.4mm to 14mm) using the AS portal and 2.1mm (range 0mm to 5.5mm) using the RI portal, a statistically significant (p=<0.001, 95% CI (-7.81, -4.04)) difference of 5.92mm. For the posterior anchors (defined as the eleven o’clock anchor for the right shoulder and one o’clock anchor for the left shoulder) the perforation rate was 80% and 60% for the AS and RI portals, respectively. There was no statistical difference found in the distance from the anchor tip to the suprascapular nerve for the posterior anchors between the AS and RI portals (p=0.36, 95% CI (-6.11, 2.51)). There was no statistical difference in the length of anchor tip exposed between the AS and RI portals for either the posterior (p=0.26, 95% CI (-0.26,0.83)) or far posterior (p=0.9, 95%CI (-4.27, 4.81)) anchors. In addition, there was no statistical difference found in the drill hole depth between the AS and RI portals for either the posterior (p=0.06, 95% CI (-0.23,7.34)) or far posterior (p=0.10, 95% CI (-0.43, 3.76)) anchors. Using an anterosuperior or rotator interval portal results in consistent penetration of 1 o’clock and 2 o’clock posterior suture anchors and may as a result place the suprascapular nerve at risk of iatrogenic injury. Based on the high likelihood of glenoid perforation and closer proximity of the suture anchor tip to the suprascapular nerve, the risk of injury is significantly greater when using a rotator interval portal in performing SLAP repair.

Suprascapular nerve injury during arthroscopic superior labral repair: a prospective evaluation

This prospective study evaluated suprascapular nerve injury risk during arthroscopic superior labral repair in patients of average height or shorter. From 2009 to 2011, 12 patients <179 cm tall undergoing arthroscopic superior labral repair were prospectively enrolled. Portal location, tear and anchor characteristics, and surgeon impression of medial glenoid wall perforation were collected. Suprascapular nerve conduction studies were obtained postoperatively. A musculoskeletal radiologist evaluated medial glenoid wall perforation and the distance from the anchor to the suprascapular neurovascular bundle on postoperative magnetic resonance images (MRI). DASH scores were recorded preoperatively and 6 months postoperatively. Medial wall perforation occurred in five (42 %) patients, with 3 patients having a single perforation and two patients having two perforations. Eight of 38 (21 %) anchors drilled into the superior half of the glenoid, and 6 of 20 (30 %) anchors inserted into the postero-superior quadrant of the glenoid, perforated the medial wall. Perforations occurred both through the portal of Wilmington and the antero-superior portal. The distance to the suprascapular neurovascular bundle from the perforating anchors ranged from 0 to 4 mm. Nerve conduction studies revealed subclinical signs of an incomplete nerve injury in one patient. DASH scores improved on average 29.3 points postoperatively (SD = 27.0, p = 0.007). Medial wall perforation is common in smaller patients during arthroscopic superior labral repairs; the suprascapular nerve can be injured if perforation occurs. The clinical significance of these findings is unclear. In spite of a high drill-out rate, the nerve is rarely injured; however, an anchor designed for implantation into bone that is instead lodged in the soft tissues has the potential to harm these tissues and surrounding structures. Prospective cohort study, treatment study, Level III.

Injury to the Suprascapular Nerve During SLAP repair

Objectives:The suprascapular nerve is potentially at risk during superior labrum repair. We compared risk of injury to the suprascapular nerve during suture anchor placement through an anterosuperior versus a rotator interval portal. Our hypothesis was that the rotator interval portal provides a safer and more reproducible method for repair of Type-II SLAP tears.Methods:Each pair of ten bilateral fresh human cadaveric shoulders was randomized to suture anchor placement through an anterosuperior portal on one shoulder and a rotator interval portal on the contralateral shoulder. Suture anchors were placed into the glenoid rim (one o’clock, eleven o’clock, and ten o’clock positions for right shoulder; eleven o’clock, one o’clock, and two o’clock for left shoulder). Standard 3 × 14 mm suture anchors were placed, and the suprascapular nerve was carefully dissected. When glenoid perforation occurred, the distance from the suture anchor tip to the suprascapular nerve was measured. The anchors were removed, and the distance from the glenoid rim to the suprascapular nerve and drill hole depth at each suture anchor entry site was recorded.Results:All far posterior suture anchors (ten o’clock anchor for right shoulders, two o’clock anchor for left shoulders) perforated the glenoid rim using the anterosuperior or rotator interval portal. For the far posterior anchor, distance from anchor tip to suprascapular nerve averaged 8.02 mm (range, 3.4 to 14 mm) using the anterosuperior portal and 2.1 mm (range, 0 to 5.5 mm) using the rotator interval portal, a statistically significant difference of 5.92 mm (95% confidence interval [CI]: −7.81 to −4.04; p ≤ 0.001).Conclusion:Using an anterosuperior or rotator interval portal results in consistent penetration of one o’clock and two o’clock posterior suture anchors and may place the suprascapular nerve at risk of iatrogenic injury. Based on the high likelihood of glenoid perforation and closer proximity of the suture anchor tip to the suprascapular nerve, the risk of injury is significantly greater with a rotator interval portal for superior labrum anterior and posterior repair.Clinical Relevance:It is important to recognize the high rate of glenoid perforation and risk of injury to the suprascapular nerve when placing anchors in the posterior glenoid from either portal.

Paper 181: Arthroscopy Findings of 200 Cases of Recurrent Anterior Dislocation of Shoulder and Results of the Technique of ''Restoring the Hammock''

One of the aims of development of any new surgical technique should be to restore the anatomy. Arthroscopy findings of 200 shoulders with recurrent anterior dislocation were evaluated to establish the pathologic anatomy. Based on these findings, a simple classification of capsule-labrum injury is proposed and a modification of the standardised arthroscopic stabilization technique is described. The results of this technique of ''restoring the hammock'' with minimum 2 years follow-up is presented. Two hundred shoulders in 188 patients, with recurrent anterior dislocation underwent arthroscopic stabilization from Jan 2003 to March 2005. There were 176 males and 12 females. Eleven males and 1 female had bilateral dislocations. The average age of the patientt was 24 years (18-42). The average numbar of dislocations was 8 (2-60) and the average time to surgery was 22 months (8-44). Overhead sports was played by 106 patients at recreational level; 28 were semiprofessional and 14 were professional. Forty patients did not play any sports and none were involved in contact sports. Systematic arthroscopic evaluation was done in lateral decubitus. Arthroscopic stabilization was performed using 3 portals. The arthroscope was in the antero-superior portal, instrumentation was done through antero-inferior portal and suture handling through posterior portal. The capsule-labrum complex was mobilized and reattached to the face of glenoid using 3 bioanchors loaded with fibrewire at 5,4, and 3 o'clock position. With the idea of tightening the whole of inferior capsule, two capsule-tuck sutures were taken in the postero-inferior capsule. A bite was taken through the posterior inferior capsule about a centimeter away from the glenoid, the needle then pierced throught the intact labrum at around 7'o clock position. The suture when tightened therby gathers the capsule. Same step was repeated at 8'o clock position. The shoulder was immobilized in a sling for 3 weeks followed by range-of-movement exercises. Strengthening exercises were initiated from third month and overhead activities including sports were permitted after 6 months. The patients were evaluated for pain, range-of-movement, stability and shoulder function after a minimum of 2 year since surgery. Objective assessment was done using Constant score. Subjective assessment was done by asking the patinent whether he or she was satisfied or not with the result. Several observations were seen consistently and likely to have an impact on the fundamental approach to recurrent anterior dislocation of shoulder.Observation 1:All patients had antero-inferior rather than anterior dislocation as evident on arthroscopic evaluation. Observation 2:99% of the shoulders has a capsule-labrum injury(Bankart lesion).Observation 3:The extent of damage to the capsule-labrum complex was variable. Based on these findings a classification is proposed.Observation 4:18% of the shoulders had a SLAP lesion. None has a HAGL lesion.The average Constant scope was 92 (88-100) and 96% were satisfied with the result. Four shoulder (2%) redislocated with in 2 years of the surgery. Three has a fall and 1 had an indirect injury. Two patients who had a recurrence due to a fall were reoperated and arthroscopy revealed a Bankart lesion. None of the patients with a bony Bankart lesion had recurrence of instability. 92% of the patients could return to overhead sports, however only 77% could perform at pre-injury level. One patient presented with severe pain and stiffness in the shoulder 14 weeks post op. Clinical and blood investigations did not reveal any evidence of infection. Xrays showed bony erosion probably due to reaction to the bioabsorbable anchor. However the symptoms resolved with rest anti-inflammatory medications. Recurrent anterior dislocation of shoulder is in fact antero-inferior. Detachment of the antero-inferior capsule/labrum and stretching of the inferior capsule seems to be the main abnormality in recurrent anterior dislocation of shoulder. The inferior component of instability can be addressed by directly tightening of both anterior and posterior part of the inferior glenohumeral ligament. Results of arthroscopic stabilisation are comparable to open techniques.

관절경하 AO 무두 압박 나사를 이용한 견갑골 전방 관절와 분쇄 골절의 치료 - 증례 보고 -

Purpose: We present a case of anterior glenoid rim comminuted fracture that was treated with arthroscopic reduction and an AO headless compression screw (HCS) fixation. Materials and Methods: A 31-year old man complained of left shoulder pain after falling down on stairs. The anterior glenoid comminuted fragments were arthroscopically reduced. Fixation with an AO HCS was done after placement of 1.1 mm Kirschner wire as a guide pin through a standard cannulated anterosuperior portal. Results: Twelve months after the operation, union of the fracture was achieved and the range of motion was fully recovered. He did not complain of any discomfort during his activities of daily living. Conclusion: An AO HCS had various screw sizes and this was good for fixation of a small glenoid fracture and a long drill bit and screw driver were useful for fixation of deep seated glenoid fracture. A short guide wire could be replaced by a 1.1 mm K-wire. An AO HCS was useful for fixation of an anterior glenoid rim comminuted fracture.

The Di Giacomo Technique: Simplified Suture Passing in SLAP Repair

A 30° arthroscope is introduced via the posterior soft spot portal, and an anterosuperior portal is created with the use of a 7-mm disposable cannula. The anterosuperior portal is used for instrumentation. An 18-gauge spinal needle is passed via the portal of Neviaser and the rotator cuff into arthroscopic view above the superior labrum. A No. 1 polydioxanone suture (PDS; Ethicon, Somerville, NJ) is advanced through the spinal needle. An arthroscopic retriever or meniscal clamp is used to retrieve the free end of the suture and bring it out through a small anterior stab wound. A suture anchor is inserted via the anterosuperior portal into the superior neck of the glenoid. The more medial limb of the No. 2 Ethibond suture (Ethicon) from the suture anchor is retrieved with the inferior limb of the No. 1 PDS suture, and both are brought out through the anterosuperior cannula. The opposite end of the No. 1 PDS suture is then manually pulled, while, under direct arthroscopic visualization, the No. 2 Ethibond suture, now tied to the opposite end of the PDS, is pulled through the superior labral tissue. That anchor suture is retrieved and is placed outside the cannula that contains the other anchor suture. Standard arthroscopic knot tying is then employed.

Simplified Single-Portal V-Shaped SLAP Repair

Abstract We present a simplified and cost-effective method for repair of a type II SLAP lesion that requires only 1 working portal in the rotator interval—the lateral anterosuperior portal (LASP)—which is about 3 cm more lateral than the standard ASP. The rotator cuff tendon or muscle are not violated when using this portal, which provides an unproblematic 30° angle for the drill hole. The biceps root can be firmly reattached anteriorly and posteriorly using 1 double-loaded absorbable bone anchor with a suture eyelet. The first stitch is performed using a straight suture hook to pierce the anterior biceps root from the front. A PDS utility suture helps to shuttle the braided suture in a retrograde manner through the labrum. We then tie a sliding knot seating solidly on top of the labrum. The second stitch is placed with a 45° curved suture hook allowing us to pierce the labrum posteriorly to the biceps from above. Again, a sliding knot will be seated on top of the posterior biceps root, pressing it firmly onto the previously abraded bone. The completed repair looks like a V and produces secure fixation of the biceps, thus eliminating the peel-back phenomenon.

Arthroscopic Technique of Interposition Arthroplasty of the Glenohumeral Joint

Arthroscopic glenohumeral interposition arthroplasty is performed with the patient placed in the lateral decubitus position. Standard posterior, anterior, and anterosuperior portals are created, a routine diagnostic arthroscopy is performed, and the joint is débrided with the use of an arthroscopic shaver. An arthroscopic burr is used to resect prominent osteophytes, to alter the version of the glenoid if necessary, and to create microfractures on the glenoid surface. Next, 3 absorbable sutures are passed percutaneously with a 30° angled suture grasper from 3 different sites posteriorly through the posterior capsular–labral tissue and into the anterior portal cannula, where they are isolated by means of the suture saver kit. The prepared interposition membrane/tissue (GRAFTJACKET Regenerative Tissue Matrix, Wright Medical Technology, Inc., Arlington, TN) is tagged with the 3 sutures in the anterior cannula before it is introduced into the joint. Three additional sutures are attached to the membrane anteriorly at 1, 3, and 5 o’clock positions and are isolated with suture savers. The membrane is next introduced into the joint through the anterior cannula and is aligned with the glenoid rim. The anterior sutures are rerouted through the anterior capsular–labral tissue with a 70° angled suture grasper, and they are retrieved through the anterior cannula. Intra-articular nonsliding knots are used anteriorly to anchor the interposition tissue to the anterior glenoid labrum and capsule. The posterior sutures are knotted intra-articularly, or they may be tied extra-articularly; the proximal and distal posterior sutures are retrieved subcutaneously out through the skin tract of the posterior portal and are knotted with the suture present in this portal, with the use of nonsliding knots. Stability of the interposition tissue is assessed by movement of the glenohumeral joint through its entire range of motion. The postoperative protocol consists of early passive exercises, active exercises after 3 weeks, and muscle-strengthening exercises after 6 weeks.

Rotator Interval Closure After Arthroscopic Capsulolabral Repair: A Technical Variation

Abstract Rotator interval tear is one of the lesions identified in patients with glenohumeral instability. We present our technique for arthroscopic interval capsule repair. After having performed Bankart reconstruction, we pull the anterosuperior cannula back some millimeters and introduce a Penetrator suture retriever forceps (Arthrex, Naples, FL) through the upper interval capsule into the joint. Then we also remove some millimeters of the anterior cannula and introduce a suture passer (Spectrum; Linvatec, Largo, FL) loaded with a monofilament suture through the lower interval capsule. The suture is pushed into the joint and, using the Penetrator suture retriever forceps, we retrieve it out of the joint. This suture is replaced if desired by a permanent braided suture. Next, a suture passer (Arthrex) advances the end of the suture from the anterosuperior portal into the joint. The suture is retrieved out of the joint from the anterior cannula with a crochet hook. We tie the suture down the anterior cannula to close the anterior capsule. Because we use cannulas, we can use a sliding knot. The degree of tightening can be observed directly under arthroscopic view but the knot is outside of the capsule. We believe that this method is easy, effective, and reproducible.

Arthroscopic distal clavicle resection from a bursal approach

We retrospectively reviewed 117 consecutive patients who underwent arthroscopic acromioclavicular joint (ACJ) arthroplasties. Only patients who underwent ACJ arthroplasties from a bursal approach in conjunction with subacromial decompression were included. Patients with isolated ACJ arthrosis treated with resection of the distal clavicle from a superior approach, isolated impingement with only undersurface distal clavicle debridement, prior surgery, or other shoulder pathology were excluded. Twenty-four patients met these rigid criteria for inclusion in the study. After an arthroscopic subacromial decompression, the distal clavicle was visualized and resected through a standard bursal approach. In addition, an anterosuperior portal was used in 50% of the patients to confirm adequate clavicle resection. Postoperative follow-up averaged 32.5 months (range, 24 to 70 months). Preoperative and postoperative pain were rated subjectively on a 5- point scale (1, incapacitating pain; 5, no pain). Operative reports and postoperative radiographs were reviewed to determine technical factors that may have influenced outcome. Seventeen patients had excellent results (71%), 4 good (16.5%), and there were 3 failures (12.5%). Average preoperative pain rating was 1.8 and was improved to 4.3 postoperatively. The average amount of clavicle resection was only 5.4 mm. Given smooth, even, and complete bone removal, the amount of bone resected did not correlate with outcome. Arthroscopic distal clavicle resection performed in conjunction with subacromial decompression gave excellent results, comparable to isolated ACJ procedures. In this series, additional use of an anterosuperior portal for more direct shaver placement and complete ACJ viewing allowed consistent bone resection and excellent results in a high percentage of patients. Arthroscopy 1998 Jan-Feb;14(1):52-6