KNOTLESS ARTHROSCOPIC GLENOID LABRAL STABILIZATION FOR A 270° TEAR WITH CONCURRENT REMPLISSAGE IN THE LATEREAL DECUBITUS POSITION
Figure 1 - Setup for a lateral decubitus arthroscopic stabilization procedure of the left shoulder. (A) Posterior view of the patient in the right decubitus position with an inflated beanbag in place and with additional taping to ensure adequate security. An axillary roll is placed under the right axilla to prevent compression of the right shoulder axillary nerve. Padding is placed under the downfacing fibular head and between the legs to prevent pressure on bony prominences and the peroneal nerve. (B) Over-the-top view of a patient in the lateral decubitus position. (C) View from the posterior aspect of the patient after sterile draping showing the left arm in suspension with application of a pneumatic limb positioner on the surgical side of the bed and an arm holder in the left axilla attached on the nonoperative side of the bed. (D) A series of rolled sterile towels are then placed under the arm jack to assist with lateral distraction and maximize circumferential visualization.
Labral tears resulting in 270° near-circumferential pathology predispose patients to recurrent instability and are technically challenging to repair. Furthermore, when such lesions are associated with Hill-Sachs lesions, recurrent instability risk is significantly increased and can result in substantially lower clinical outcomes. When determining a surgical treatment algorithm for shoulder stabilization, it is important to consider both humeral- and glenoid-sided pathology because subtle defects can have significant influence on recurrence and patient reported outcomes. In this Technical Note and accompanying video, we discuss our surgical technique for knotless arthroscopic stabilization for a 270° labral tear with concurrent remplissage in the setting of recurrent shoulder instability.
Figure 2 - Anterior and posterior views of the left shoulder with portal placement marked. Standard outlines of the clavicle, acromion, coracoid, and acromioclavicular joint are drawn after first palpating the landmarks. (A) Anterior view of the left shoulder with the anterior superior portal, mid-glenoid, and 5 o'clock position portal. (B) Posterior view of the left shoulder with a standard posterior portal, as well as an accessory and 7 o'clock portal.
Figure 3 - Anterior superior viewing portal of a left shoulder during diagnostic evaluation of the glenohumeral joint. (A) Posterosuperior, (B) inferior, and (C) anterior aspects of the labrum showing evidence of tearing and fraying of the labrum. No evidence of arthritic changes at the glenoid or humeral head is noted.
Figure 4 - Arthroscopic view of establishing anterosuperior and mid glenoid portals of the left shoulder while viewing from the posterior portal. (A, B) A spinal needle is used to establish a trajectory just superior to the subscapularis, with an angle that will allow for perpendicular drilling into the glenoid and suture passing through the labrum. This will serve as the mid glenoid portal. (C) An anterosuperior portal is established using spinal needle localization, just posterior to the biceps tendon that is used for visualization throughout the case.
Figure 5 - Knotless remplissage procedure of the left shoulder for a Hill-Sachs deformity while viewing from the anterior superior portal. (A) Hill-Sachs deformity of the left shoulder during diagnostic arthroscopy. (B, C) Placement of 2 all-suture knotless anchors in the defect site of the Hill-Sachs deformity that are placed through the posterior rotator cuff and capsule and passed through a cannula in the subdeltoid space.
Figure 6 - Knotless 270° labral repair of the left shoulder while viewing from the anterior superior portal position. (A, B) Placement of two posteroinferior knotless tensionable anchors in the left shoulder. (C) View of the anterior and inferior portions of the labrum after all knotless anchors have been placed prior to final tightening and cutting of the sutures. (D) Final construct of the anterior and inferior labral repair.
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Published October 20, 2022 in Arthroscopic Techniques (Volume 11 - Issue 11).