Rockwood Adults CH34

1094

SECTION TWO • Upper Extremity

flexion, abduction, and external rotation is documented. Sul- cus sign with the arm in neutral and external rotations is also recorded. The posterior viewing portal is established with a no. 11 blade in the soft spot (usually ∼ 2 cm down and ∼ 1 cm over from the posterior lateral edge of the acromion; Fig. 34-30B). Diagnostic arthroscopy is performed to evaluate for labral tears, rotator cuff, biceps, cartilage, glenoid bone loss, bony Bankart lesions, and humeral head bone loss (Hill–Sachs lesion). A 30-degree scope is used for the procedure. However, if visualiza- tion is difficult, a 70-degree scope can be used in the posterior portal to better visualize the labrum for repair. Another option is to put the 30-degree scope into the anterolateral portal. The anterolateral portal is established with assistance of an 18-gauge spinal needle ( ∼ 1 cm down from the anterolateral acromion). A posteriorly directed force on the humeral head can help with

placement of this portal by posteriorly translating the humeral head and opening up the space anteriorly. A threaded cannula (6 mm) is inserted via a switching stick. This is the working portal (Fig. 34-30C, circle ). An anteroinferior portal is established with the assistance of an 18-gauge spinal needle just above the subscapularis muscle belly and slightly above the surface of the glenoid fossa (Fig. 34-30C, arrow ). Alternatively, this portal position can be estab- lished with an inside-out technique. Another threaded cannula (8 mm) is inserted via a switching stick. An 8-mm cannula is used to allow for the passage of the curved passer. This is the suture passing and drilling portal for all anchors. A labral eleva- tor or CoVator (Fig. 34-31A, star ) is inserted into the anterolat- eral portal to mobilize the anteroinferior capsulolabral complex (Fig. 34-31A, arrow ) off the glenoid rim. It is critical that the labrum is mobilized off the glenoid so that the subscapularis

A

B

C

D

Figure 34-31.  A: Anterior–inferior labral tear is identified ( arrow ) and the CoVator is used to mobilize the anterior–inferior labrum off the glenoid neck. B: The subscapularis muscle belly must be visualized ( star ) to confirm adequate shift of the capsulolabral complex will be obtained. C: A curved passer with a metal tipped suture shuttle ( arrow ) is used to shift the capsulolabral complex. D: The first anchor must be low on the anterior inferior glenoid rim.