Rockwood Adults CH34

1093

CHAPTER 34 • Glenohumeral Instability

A, B

C

Figure 34-30.  A: Lateral decubitus position for arthroscopic Bankart repair. Balance traction of the gleno- humeral joint is obtained with both distraction and traction. Additionally, a small bump is placed under the axilla to help further distract the joint ( arrow ). B: Posterior viewing portal ( arrow ) and posterior lateral accessory portal ( circle ) used for drilling and placement of anchors for posterior labral repair. This portal must be in line or parallel with the spine of the scapula. C: Anterior inferior portal ( arrow ) used for suture passage and also drilling and anchor placement. Anterior superolateral accessory portal ( circle ) used for suture management and shuttling. This portal must be placed slightly under the lateral edge of the acro- mion so that it is spaced away from the anterior inferior portal.

placed underneath the axilla to help further distract the gleno- humeral joint to allow for better visualization. The authors pre- fer the lateral decubitus position over the beach chair position for arthroscopic labral repair. Surgical Approach A posterior portal is placed approximately 2 cm below and 1 cm over from the posterior lateral edge of the acromion (Fig. 34-30B, arrow ). The trochar is inserted toward the cora- coid and in between the glenohumeral joint. A 30-degree scope is used to start the diagnostic arthroscopy. Complete evalua- tion of the glenohumeral joint is needed to identify any pathol- ogy to the labrum, cartilage, rotator cuff, humeral head, and other intra-articular structures within the glenohumeral joint. Two portals are established anteriorly with one as the work- ing portal and the other as the drilling portal (Fig. 34-30C). The anterolateral portal is established with the assistance of a spinal needle and located within 1 cm of the anterolateral edge of the acromion (Fig. 34-30C, circle ). This portal is right next to the anterior leading edge of the supraspinatus tendon over the biceps tendon. The anteroinferior or the 5:30 portal is also established with the assistance of a spinal needle placed right over the tendon of the subscapularis muscle and slightly above the glenoid fossa to allow for drilling and suture passing across the labrum (Fig. 34-30C, arrow ). This portal must have a diameter with a large enough cannula (8 mm) to accommo- date the curved passer. We prefer to use the metal passer that is 45 degrees which requires an 8-mm cannula. A right curved passer is used when the affected side is the right shoulder and vice versa. In the setting of associated posterior labral tear, the viewing is switched to the anterior portal and the working por- tal is posterior. It is essential that the accessory posterior lateral portal used for drilling and insertion of the anchor is in line

with the spine of the scapula (Fig. 34-30B, circle ). Otherwise, the anchor may penetrate the glenoid fossa.

Technique

✔ ✔ Arthroscopic Anterior Labral (Bankart) Repair: KEY SURGICAL STEPS

❑❑ Lateral decubitus or beach chair position ❑❑ Examination under anesthesia ❑❑ Establish posterior viewing portal ❑❑ Diagnostic scoping ❑❑ Establish anterolateral and anteroinferior portals

❑❑ Mobilize the anteroinferior capsulolabral off the glenoid rim ❑❑ Penetrate the capsule using a curved passer to allow shifting and mobilization of the capsulolabral complex ❑❑ Position first anchor low on the glenoid face and pass labral tape ❑❑ Cut the passed labral tape down to the rim of the glenoid ❑❑ The same steps are repeated with two to three additional passages of the passer, labral tape, and fixation of the Bankart lesion to the anterior glenoid rim ❑❑ Create a bumper at the end of the case that shows excellent shift of the anterior-inferior capsulolabral complex ❑❑ Insert scope into the anterolateral portal to evaluate the repair ❑❑ Place patient in a sling with abduction pillow ❑❑ Follow standard postoperative protocol The lateral decubitus (Fig. 34-30A) or beach chair position is used. (The authors prefer lateral decubitus positioning due to the balanced traction placed on the affected extremity that allows better visualization to the anteroinferior labrum for repair.) Small bump underneath the axilla will help with visual- ization by joint distraction (Fig. 34-30A). Load and shift exam- ination under anesthesia is performed to document humeral head translation (1 + is to the rim and back, 2 + past the rim and back, and 3 + is locked out past the rim). ROM in forward