Arthroscopic Evaluation
The patient is seated in the beach-chair position while under general
anesthesia, and joint laxity is assessed by means of an examination of both
shoulders prior to surgical intervention. A 4-mm arthroscope is introduced
through a standard posterior portal, and diagnostic arthroscopy is performed.
An anterior portal is then created just superior to the subscapularis tendon
and lateral to the conjoined tendon with use of an outside-in technique to
facilitate instrument insertion without
cannulas9. Inserting
the arthroscope through the anterior portal also can help to confirm a large
osseous glenoid defect of the anteroinferior quadrant. Normally, an osseous
fragment that is covered by or embedded in the surrounding labroligamentous
complex is observed arthroscopically if the defect is large enough (Figs.
1-A, 1-B, and
1-C).
Mobilization of the Complex
After investigation from the anterior portal, separation and mobilization
of the labroligamentous complex together with the osseous fragment from the
glenoid neck are performed with use of an elevator, straight and curved rasps,
scissors, shavers, and a radiofrequency instrument (VAPR; DePuy Mitek,
Raynham, Massachusetts) through the anterior portal. This procedure is a
critical part of the operation. First, a straight rasp is inserted from the
anterior portal and is placed in the small gap between the fragment and the
glenoid neck. Then, the gap is expanded by tapping the handle of the rasp.
After separation of the fragment from the glenoid neck, mobilization of the
labroligamentous complex is performed up to the 6:30 position in the right
shoulder until the complex and the fragment become completely free, in exactly
the same way as one would mobilize a Bankart lesion without an osseous
fragment, with use of the instruments previously described. Normally, although
the displaced osseous fragment is partly united to the glenoid neck, the
separation of the fragment from the neck can still be done easily with use of
only elevators and rasps. If the separation of the fragment is difficult and
the fragment is united firmly, however, a small chisel (instead of a straight
rasp) can be introduced from the anterior portal to separate the fragment from
the glenoid neck (Figs. 2-A,
2-B, and 2-C).
Then, an anterosuperior portal is established at the anterosuperior margin of
the rotator interval, which is directly behind the biceps tendon as seen from
the posterior portal, with use of an outside-in technique. This will be the
second working portal. In shoulders with superior labral detachment, a lateral
acromial portal, established just lateral to the midpoint of the acromion
through the muscle-tendon junction of the infraspinatus, is used instead of
the anterosuperior portal.
CRITICAL CONCEPTSINDICATIONS:The procedure is indicated for all shoulders with recurrent traumatic
anterior glenohumeral instability associated with an osseous fragment at the
anteroinferior quadrant of the glenoid as determined by means of preoperative
three-dimensionally reconstructed computed tomography, including both primary
and revision cases.CONTRAINDICATIONS:There are no contraindications for this procedure.PITFALLS:Rasps should be placed firmly on the glenoid neck during the separation of
the fragment and labrum from the neck; otherwise, injury to the axillary nerve
or vessels may occur. When using a chisel to separate the united fragment from
the glenoid neck, the surgeon should take care not to allow the sharp tip of
the chisel to penetrate too deeply.The inferior labrum should be separated up to or just beyond the 6 o'clock
position during the mobilization; otherwise, the reduction of the fragment as
well as the tensioning of the anterior glenohumeral ligament may be
insufficient.Penetrating the fragment with use of bone-penetrating instruments is
sometimes very difficult. Technical tips for this procedure include holding
the complex with use of graspers to stabilize the fragment and aiming the
penetrating instrument perpendicular to the fragment when piercing the cortex
so as to avoid damaging or breaking the instrument.In our experience, the glenoid morphology eventually approximates a normal
circular configuration after repair even if the fragment is small compared
with the defect size because of remodeling of the repair site. We believe that
tightening of the inferior glenohumeral ligament by reducing the osseous
fragment is far more important in terms of restoring normal capsular anatomy
and function than bone-grafting the fragment site to fill the remaining
defect.AUTHOR UPDATE:Currently, we use the Lupine Loop anchor (Mitek) loaded with dual #2
sutures for the repair because the anchor size is smaller and the suture
eyelet is stronger as compared with the Panalok anchor (DePuy Mitek).Currently, we also use an originally designed bone-penetrating instrument
with a stronger shaft and larger handle during the bone-penetrating procedure.
Otherwise, in shoulders with a large fragment, we create a hole in the
fragment with use of a Kirschner wire that is inserted from the anteroinferior
portal to pass the suture through the fragment.
CRITICAL CONCEPTS
INDICATIONS:
The procedure is indicated for all shoulders with recurrent traumatic
anterior glenohumeral instability associated with an osseous fragment at the
anteroinferior quadrant of the glenoid as determined by means of preoperative
three-dimensionally reconstructed computed tomography, including both primary
and revision cases.
CONTRAINDICATIONS:
There are no contraindications for this procedure.
PITFALLS:
Rasps should be placed firmly on the glenoid neck during the separation of
the fragment and labrum from the neck; otherwise, injury to the axillary nerve
or vessels may occur. When using a chisel to separate the united fragment from
the glenoid neck, the surgeon should take care not to allow the sharp tip of
the chisel to penetrate too deeply.The inferior labrum should be separated up to or just beyond the 6 o'clock
position during the mobilization; otherwise, the reduction of the fragment as
well as the tensioning of the anterior glenohumeral ligament may be
insufficient.Penetrating the fragment with use of bone-penetrating instruments is
sometimes very difficult. Technical tips for this procedure include holding
the complex with use of graspers to stabilize the fragment and aiming the
penetrating instrument perpendicular to the fragment when piercing the cortex
so as to avoid damaging or breaking the instrument.In our experience, the glenoid morphology eventually approximates a normal
circular configuration after repair even if the fragment is small compared
with the defect size because of remodeling of the repair site. We believe that
tightening of the inferior glenohumeral ligament by reducing the osseous
fragment is far more important in terms of restoring normal capsular anatomy
and function than bone-grafting the fragment site to fill the remaining
defect.
Rasps should be placed firmly on the glenoid neck during the separation of
the fragment and labrum from the neck; otherwise, injury to the axillary nerve
or vessels may occur. When using a chisel to separate the united fragment from
the glenoid neck, the surgeon should take care not to allow the sharp tip of
the chisel to penetrate too deeply.
The inferior labrum should be separated up to or just beyond the 6 o'clock
position during the mobilization; otherwise, the reduction of the fragment as
well as the tensioning of the anterior glenohumeral ligament may be
insufficient.
Penetrating the fragment with use of bone-penetrating instruments is
sometimes very difficult. Technical tips for this procedure include holding
the complex with use of graspers to stabilize the fragment and aiming the
penetrating instrument perpendicular to the fragment when piercing the cortex
so as to avoid damaging or breaking the instrument.
In our experience, the glenoid morphology eventually approximates a normal
circular configuration after repair even if the fragment is small compared
with the defect size because of remodeling of the repair site. We believe that
tightening of the inferior glenohumeral ligament by reducing the osseous
fragment is far more important in terms of restoring normal capsular anatomy
and function than bone-grafting the fragment site to fill the remaining
defect.
AUTHOR UPDATE:
Currently, we use the Lupine Loop anchor (Mitek) loaded with dual #2
sutures for the repair because the anchor size is smaller and the suture
eyelet is stronger as compared with the Panalok anchor (DePuy Mitek).
Currently, we also use an originally designed bone-penetrating instrument
with a stronger shaft and larger handle during the bone-penetrating procedure.
Otherwise, in shoulders with a large fragment, we create a hole in the
fragment with use of a Kirschner wire that is inserted from the anteroinferior
portal to pass the suture through the fragment.
Repair of Inferior Labrum Adjacent to the Osseous Fragment
Once the mobilization of the fragment and the complex is completed,
preparation of the glenoid is performed by removing scar tissue from the
glenoid neck and exposing the osseous surface with use of a shaver and an
abrader. Furthermore, articular cartilage on the edge of the glenoid is also
removed to promote tissue-healing after repair
(Figs. 3-A and 3-B). In total,
three or four bioabsorbable suture anchors (Lupine Loop; DePuy Mitek) loaded
with #2 permanent suture (Ethibond; Ethicon, Somerville, New Jersey) are next
inserted on the edge of the glenoid with use of a drillguide that is
introduced through the anterior portal. Because this portal has no cannula,
the angle of approach of the guide can be adjusted easily to optimize the
angle to the
glenoid9. After the
first anchor insertion, the labrum adjacent to the inferior side of the
osseous fragment is secured with use of a modified Caspari punch (Linvatec,
Largo, Florida) or a Suture Hook (Linvatec) loaded with a looped #2-0 nylon
suture. A suture relay is performed
intra-articularly9.
After completion of the suture relay, and following the insertion of a 5-mm
cannula into the anterior portal, knot-tying is performed with use of a
self-locking sliding knot. To accomplish secure knot-tying, the complex,
together with the fragment, is held upward and laterally on the glenoid
surface with a grasper that is introduced through the accessory working portal
to reduce tensile force on the suture.
Osseous Fragment and Superior Labrum Repair
The next step is the suturing of the osseous fragment itself, either by
passing the suture through the fragment or penetrating the fragment with use
of bone-penetrating tools such as a Suture Leader (DePuy Mitek) or Ideal
Suture Grasper (DePuy Mitek) or by passing the suture around the fragment with
use of a Suture Hook (Linvatec) or Suture Leader (DePuy
Mitek)2,8.
It is very important to characterize the fragment shape and size
preoperatively by means of three-dimensionally reconstructed computed
tomography to decide whether passing through or passing around the fragment is
most appropriate (Figs. 4-A and
4-B). This procedure is
facilitated when the osseous fragment is reduced and stabilized by grasping
the labrum adjacent to the superior portion of the fragment with a grasper as
described earlier for the first knot-tying. Although the number of suture
anchors depends on the size and shape of the osseous fragment, normally one or
two suture anchors are used in this process
(Fig. 5). Knot-tying is
performed after placing the sutures through the fragment. The final step is to
suture the labrum adjacent to the superior side of the fragment with use of an
Ideal Suture Grasper (DePuy Mitek) to augment the stability of the entire
complex. Three or four suture anchors with simple sutures are used to
reconstruct the entire labroligamentous complex (Figs.
6-A and
6-B).
Management of the Associated Pathology
In shoulders with a capsular tear, capsular repair with use of #2 Ethibond
(Ethicon) by means of two to three side-to-side stitches is performed prior to
the osseous Bankart repair. Furthermore, in shoulders with a superior labral
detachment, arthroscopic reattachment is performed with use of the same suture
anchors, through a lateral acromial portal instead of the anterosuperior
portal, following the osseous Bankart repair.
Rotator Interval Closure
The rotator interval closure is now performed as an augmentation in
patients with relatively high-risk shoulders, such as those who are contact
athletes, those who are young, those who have laxity, and those who have a
large (Rowe
grade-III10)
Hill-Sachs lesion. In those patients, the rotator interval is closed by
suturing the superior margin of the subscapularis tendon to the superior
glenohumeral ligament with the arm held at the side and in maximum external
rotation with use of #2 permanent
sutures11
(Figs. 7-A and 7-B).
Postoperative Protocol
The shoulder is immobilized for three weeks with use of a sling (Ultra
Sling II; Donjoy, Vista, California). After immobilization, passive and
active-assisted exercises are initiated for forward flexion and external
rotation, avoiding the provocation of pain. After six weeks, the patient
begins to perform strengthening exercises of the rotator cuff and the scapular
stabilizers. Three months after the operation, the patient is permitted to
practice noncontact sports. Full return to throwing or contact sports is
allowed after six months, according to each individual's functional
recovery.