Arthroscopic "cuff-sparing" percutaneous (CUSP) technique for posterior instability repair in the beach-chair position

Patient Positioning in Arthroscopic Management of Posterior-Inferior Shoulder Instability: A Systematic Review Comparing Beach Chair and Lateral Decubitus Approaches

PURPOSE

To analyze the available literature pertaining to clinical outcomes and complications of posterior-inferior shoulder stabilization performed arthroscopically in either the beach chair (BC) or lateral decubitus (LD) position.

METHODS

According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 3 databases (PubMed, EMBASE, and Medline) were searched up to January 2018 for English-language studies on posterior shoulder instability. Descriptive statistics are presented. The Methodological Index for Non-Randomized Studies (MINORS) scale was used to assess quality.

RESULTS

Twenty-five studies were included, examining 1,085 patients (n = 140 BC; n = 945 LD), of mean age 25.0 years, 27.1% female, and mean 3.1 years of follow-up. MINORS scores for BC and LD were 11.2 and 9.8, respectively. Regardless of positioning, patients did not differ across numerous outcomes and various surgical factors (e.g., number of portals, anchors, anchor types, concomitant pathology, or postoperative rehabilitation protocol). Postoperative patient satisfaction ranged from 85% to 87.5% and 93% to 100% for patients treated in BC and LD positions, respectively. Although not reported for BC, overall and preinjury return-to-play (RTP) rates in LD patients ranged from 72% to 100% and 55% to 100%, respectively, returning from 3 to 7.6 months postoperatively. Failure rates in the BC and LD positions ranged from 0% to 9.4% and 0% to 29%, respectively. There were no differences in reported incidences of neuropraxia, stroke, nonfatal pulmonary embolus, vision loss, cardiac arrest, or other positioning-related complications.

CONCLUSIONS

Arthroscopic management of posterior-inferior shoulder instability has a successful track record and minimal complication profile. Although patient positioning appears to influence results, with those treated in the LD position experiencing marginally higher patient satisfaction and failure rates, the current data prevent any conclusions being made regarding the superiority of one approach over another. As the clinical relevance of patient positioning remains to be determined, larger, higher-level study designs with long-term follow-up are required.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

The "Sublabral Window" in Arthroscopic Posterior Shoulder Instability Surgery: Description of a Technique for Safe Posterior Glenoid Preparation

Arthroscopic posterior labral repairs for posterior shoulder instability can be challenging. Preparation of the capsulolabral tissue and glenoid bony surface is critical. Iatrogenic injury to the articular cartilage and unwarranted truncation of the capsulolabral tissue are concerns during preparation. As a result, several techniques have been described to potentially avoid these complications. We describe an additional technique for improving access and preparing the capsulolabral tissue and glenoid surface through a "sublabral window." This technique approaches the posterior labrum and glenoid through an already established posterior portal and mitigates iatrogenic injury to the labrum and articular cartilage. The technique is rather simple and easily adaptable.

The split portal: Description of a new accessory posterior portal for arthroscopic shoulder instability procedures

PURPOSE

Open approach to the posterior shoulder during bone block for posterior shoulder instability is challenging. Anatomical study was performed to identify landmarks of a portal, avoiding soft tissue damage, between the infraspinatus (IS) and teres minor (TM) muscles and distant from the supra-scapular nerve (SSN) for arthroscopic shoulder bone block.

METHODS

Eight fresh-frozen cadaveric shoulder specimens were used. The arthroscope was introduced through the soft point (SP). A guide wire was placed through the SP, in the rotator interval direction. A posterior open dissection exposed the split between the IS and TM. A new guide wire was placed into the split, parallel to the first wire, to locate the new posterior arthroscopic approach. Ten distances were measured to define the safe position.

RESULTS

The mean values were: SP to split IS-TM: 2 ± 0.2 (2-2.8); spinal bone to split IS-TM: 5 ± 0.5 (3-6.2); split IS-TM to posterior glenoid 6 o'clock: 1.3 ± 0.3 (0.6-1.6), 9 o'clock: 1.5 ± 0.3 (1-1.9), and 12 o'clock: 2 ± 0.1 (2.1-2.4); SSN to posterior glenoid 6 o'clock: 2.4 ± 0.2 (2.1-2.6), 9 o'clock: 1.7 ± 0.1 (1.5-1.8), and 12 o'clock: 1.5 ± 0.3 (1.2-2.1); and SSN to split IS-TM: 2 ± 0.3 (1.2-2.1).

CONCLUSION

This preliminary anatomical study described a posterior arthroscopic portal located 2 cm under the SP, parallel to the SP portal direction, and finishing between 7 and 8 o'clock at the posterior rim of the glenoid. For arthroscopic shoulder bone block, this portal can avoid muscle and SSN lesions.

The "double-barrel" knot: a new sliding knot for arthroscopic soft tissue fixation using single-pulley and double-pulley techniques

The double-barrel knot is a new arthroscopic sliding knot for soft tissue reconstruction and repair procedures in arthroscopic and open shoulder surgery. The double-barrel knot is a modified sliding hitch, and is formed using 2 sutures from a single double-loaded anchor (single-pulley technique) or 2 sutures from 2 adjacent anchors (double-pulley technique). This paper describes the method of double-barrel knot formation, and its variations; in addition, single-pulley and double-pulley techniques for anterior glenoid labral repair are presented.