Rockwood Adults CH34

1110

SECTION TWO • Upper Extremity

and positioned lateral on a bean bag or peg board. Care must be taken to ensure there is no pressure over the fibular head to avoid pressure injury to the common peroneal nerve. The oper- ative arm is prepped and secured in a mechanical arm holder. A variety of distraction devices/arm holders are available. A device that allows for a combination of longitudinal and lateral distrac- tion is helpful for optimizing visualization and working space in the posterior shoulder. Additionally, a small sterile bump can be placed in the axilla of the operative arm to further distract the glenohumeral joint to allow for improved visualization. For the beach chair setup (Fig. 34-38A), the hips and knee are flexed to 60 degrees and the head is secured in neutral in a padded head holder. Similarly, the operative arm is secured in an arm holder which enables stable arm positioning and a small bump is fashioned for axillary placement and distraction of the glenohumeral joint. In this position, external rotation of the arm to 30 degrees will help open up the posterior capsule, room for suture passing and provides anchor fixation of the labrum (Fig. 34-38B).

18-gauge spinal needle for localization. Disposable, threaded plastic cannulas are placed and a 6-mm superior viewing portal and an 8-mm anterior and inferior working portal are used. Care must be taken to separate the cannulas so there is a bridge of tissue between the two cannulas that allows for room to maneuver instruments. Also, the incisions must not be so large as to allow the cannulas to inadvertently pull out while passing instruments through them during surgery. Once the two portals are established in the rotator interval, the viewing arthroscope is inserted in the 6-mm anterior portal while the working portal for the elevator is the anterior supero- lateral portal and a 3rd cannula (8 mm) is placed into loca- tion of the previously established posterior viewing portal (Fig. 34-38B). A diagnostic arthroscopy is performed and the extent of the posterior labral tear is evaluated. The previously estab- lished posterior viewing portal is parallel to the glenoid and is optimal for passing capsulolabral sutures and curved passers but may not allow for accurate placement of suture anchors at an appropriate insertion location and angle into the glenoid. Therefore, a percutaneous posterolateral accessory portal for anchor placement is necessary, especially for 5- to 7-o’clock posterior inferior anchors (Fig. 34-39). It is essential that this portal is in line with the spine of the scapula. Otherwise, there is a risk of the anchor penetrating the glenoid fossa. Double-loaded suture anchors should be used, as they are biomechanically superior to single-loaded anchors. Knotless anchors with labral tape can also be used but are limited to one labral tape per anchor (Fig. 34-40). Depending on the pathol- ogy encountered, a capsular shift may be a desirable goal. The capsular shift/tightening is performed by passing the suture through a fold of tissue that includes the stretched or damaged posterior-inferior glenohumeral ligament and the adjacent torn posterior labrum. If a double-loaded suture anchor is used, either two simple stitches can be used or a combination mat- tress and simple suture configuration can be performed. The anchors should be placed on the face of the glenoid 1 to 2 mm from the edge of the intact glenoid which allows for restoration of the bumper effect of the labrum and ensures the anchors have a circumferential drill hole for stable fixation (Fig. 34-40C). Depending on the style of knotless anchor, the suture or labral tape may need to be passed first through the posterior capsu- lolabral complex followed by the insertion of the anchor, while traditional knotted anchors require placement of the anchor first followed by passage of sutures and knot tying. Suture passage is achieved by either a shuttling technique or via direct passage with a penetrating suture passer such as a bird beak or curvilinear or corkscrew-style passer (see Fig. 34-39). The authors prefer a metal-tipped passer to ease the penetration through the soft tissue. For the right shoulder, posterior labral repair would require a left curved passer and vice versa. Posi- tioning in the lateral position and use of a shuttling technique with the anteroinferior cannula is less technically demanding; however, the penetrating suture passers are effective in the beach chair position and can eliminate the need for any cannulas during surgery as well as the requirement for suture shuttling. The use of penetrating graspers without cannulas is more tech- nically demanding but simplifies the equipment requirements and can enhance visualization. Knotted anchors require effective

Technique

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

❑❑ Lateral decubitus or beach chair ❑❑ Examination under anesthesia ❑❑ Establish standard posterior viewing portal ❑❑ Diagnostic arthroscopy

❑❑ Establish anterior lateral superior and anterior inferior portals ❑❑ Either knotted anchor of knotless anchors with labral tape can be used ❑❑ Place 2–4 anchors to repair the labrum back on the glenoid labrum ❑❑ Patient is placed in a sling with external rotation pillow. Standard postoperative protocol is followed The lateral decubitus or beach chair position is used. A ster- ile bump composed of several sterile towels rolled up and wrapped with a Coban is placed underneath the axilla and will help with visualization by joint distraction. (This can be done in both positions.) Load and shift test under anesthesia verifies the direction of instability. Establish a standard posterior view- ing portal approximately 1 cm inferior and 2 cm medial to the posterolateral acromion. Do not change this portal placement to improve angle for anchor insertion. A poorly placed portal will impair visualization and suture passage. Instead, use per- cutaneous anchor insertion techniques through another acces- sory posterior lateral portal that is in line with the scapular spine. The trocar and arthroscopic sheath are directed toward the coracoid process in line with the glenohumeral joint (Fig. 34-38A,B). Diagnostic arthroscopy is performed to evalu- ate for labral tears, rotator cuff, biceps, cartilage, glenoid bone loss, bony Bankart lesions, and humeral head lesions (reverse Hill–Sachs lesion). A 30-degree arthroscope is used for visual- ization. Rarely, a 70-degree arthroscope can be used in the pos- terior portal to better visualize the labrum for repair. Another option is to put the 30-degree scope into the anterolateral por- tal. Two anterior rotator interval portals—anterolateral superior and anterior inferior portals—are then established using an