The 7-o'clock posteroinferior portal for shoulder arthroscopy

Disabled Throwing Shoulder: 2021 Update: Part 2-Pathomechanics and Treatment

The purpose of this paper is to provide updated information for sports healthcare specialists regarding the disabled throwing shoulder (DTS). A panel of experts, recognized for their experience and expertise in this field, was assembled to address and provide updated information on several topics that have been identified as key areas in creating the DTS spectrum. Each panel member submitted a concise presentation on one of the topics within these areas, each of which were then edited and sent back to the group for their comments and consensus agreement in each area. Part two presents the following consensus conclusions and summary findings regarding pathomechanics and treatment, including (1) internal impingement results from a combination of scapular protraction and humeral head translation; (2) the clinically significant labral injury that represents pathoanatomy can occur at any position around the glenoid, with posterior injuries most common; (3) meticulous history and physical examination, with a thorough kinetic chain assessment, is necessary to comprehensively identify all the factors in the DTS and clinically significant labral injury; (4) surgical treatment should be carefully performed, with specific indications and techniques incorporating low profile implants posterior to the biceps that avoid capsular constraint; (5) rehabilitation should correct all kinetic chain deficits while also developing high-functioning, throwing-specific motor patterns and proper distribution of loads and forces across all joints during throwing; and (6) injury risk modification must focus on individualized athlete workload to avoid overuse. LEVEL OF EVIDENCE: V, expert opinion.

Humeral Avulsion of the Glenohumeral Ligament: Diagnosis and Management

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The most common type of humeral avulsion of the glenohumeral ligament (HAGL) is a purely ligamentous avulsion involving the anterior inferior glenohumeral ligament (IGHL), but other variants are seen, including posterior lesions and those with an osseous avulsion.

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A central lesion between the intact anterior and posterior bands of the IGHL is gaining recognition as a distinct clinical entity.

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HAGL lesions are most commonly seen in patients with anterior instability without a Bankart tear or in those with persistent symptoms despite having undergone a Bankart repair.

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Magnetic resonance imaging is the most sensitive imaging modality. An arthrogram is helpful with subacute and chronic lesions when the joint is not distended. Arthroscopy is the gold standard for diagnosis.

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While some have reported success with nonoperative management, surgical repair with either arthroscopic or open techniques has provided a high rate of successful outcomes; however, the literature is limited to mostly Level-IV and V evidence.

Determining the accurate placement of a posterior portal in shoulder arthroscopy with the use of computerized tomography images

Background

Portal placement is an important factor in performing a successful shoulder arthroscopy. Recent cadaveric studies have found variance in the anatomy of the glenohumeral joint. Our aim was to determine if computerized tomography (CT) images could be used to map the trajectory of the posterior portal objectively and then measure the distance between this trajectory and palpable landmarks to apply this knowledge to clinical practice.

Methods

Two-dimensional multiplanar reformatted CT images were generated using OsiriX (Pixmeo, Switzerland) from CT images performed in a tertiary hospital over a 1-month period. The center of the glenoid was identified and a trajectory through it radiologically mapped. Horizontal and lateral measurements were taken from this trajectory to both the posterolateral edge of the acromion and tip of the coracoid.

Results

Following application of inclusion and exclusion criteria, 226 shoulders were analyzed. Fifty scans were selected at random and re-reviewed by the primary examiner to assess intra-rater reliability which showed strong correlation and no significant differences between first and second measurements (P < .01, r > 0.6). The mean distance from acromion to portal trajectory was 1.39 cm inferiorly (95% confidence interval [CI] 1.31-1.48, standard deviation [SD] 0.65 cm) and 1.44 cm medially (95% CI 1.35-1.53, SD 0.71 cm). The mean distance from the coracoid to the trajectory was 1.71 cm inferiorly (95% CI 1.64-1.78, SD 0.55 cm) and 1.26 cm medially (95% CI 1-2-1.31, SD 0.45 cm). Paired t-test analysis between right and left shoulders within the same subject, where these data were available (n = 81), showed no significant difference (P > .05) between sides. Subset analysis was also performed between males and females, but only showed a significant difference between the vertical distance from the coracoid process to the center of the glenohumeral joint. This distance was shorter in females compared to males (1.56 cm in females compared to 1.84 cm in males, P < .001).

Conclusions

Knowledge of shoulder anatomy is vital to the placement of arthroscopic portals, yet research on this topic has been based primarily on surface anatomy, small sample sized cadaveric studies or expert opinion alone. Our study shows that posterior portal placement in shoulder arthroscopy can be measured objectively using CT scanning.

Posterior approach shoulder arthroplasty: a cadaveric study assessing access

BACKGROUND

Posterior shoulder arthroplasty is an approach to shoulder replacement. The goal of this cadaveric study was to determine anatomic feasibility for posterior approach shoulder arthroplasty by evaluating access to the glenoid, humerus, and canal.

METHODS

Twelve fresh frozen shoulders (10 males; 2 females) (mean age, 76 [range, 55-92 years]; weight, 79 kg [range, 34-125 kg]) were used. Traditional exposure techniques and retractors were used to evaluate direct access. Exposure to the glenoid and humerus was evaluated using digital imaging software. Successful placement from stemmed arthroplasty was evaluated using digital radiographs and imaging software.

RESULTS

The posterior approach permitted direct access to 88.8% ± 8.1% of the glenoid. There was access to the center of the humeral head cut surface in 12 of 12 specimens. In 10 specimens, there was 100% access to the entire cut surface of the humerus and peripheral edges. The average access to the humerus was 95.3% ± 13.4%. Average angulation with stem placement was 0.73° of varus (range, 4.4° of varus to 3.5° of valgus). Regarding lateral plane angulation, there was an average of 0.33° of posterior angulation (range, 3.3° of posterior angulation to 2.5° of anterior angulation).

CONCLUSION

Access to the center of the glenoid and humerus was achieved in all cases. More research is needed to evaluate the clinical efficacy of posterior shoulder arthroplasty, including mid- and long-term outcome and safety studies.

[Posttraumatic shoulder stiffness]

Posttraumatic stiffness of the shoulder joint is a frequent and socioeconomically relevant result of injury; however, prior to making the diagnosis as the only cause of a persisting impairment of motion, it is necessary to rule out other sequelae of trauma. Even intensive conservative treatment is mostly accompanied by the stagnation of the impairments of movement. In many cases the treatment of choice is early arthroscopic arthrolysis with a standardized approach and intensive follow-up treatment. In the surgical treatment of proximal humeral fractures with humeral head preservation, arthroscopic arthrolysis with simultaneous implant removal is a form of planned second intervention for improvement of shoulder function in cases of persisting motion deficits after bony consolidation. Despite sometimes substantial limitations of movement, a clinically relevant and lasting improvement of shoulder function can be achieved with arthroscopic arthrolysis in posttraumatic shoulder stiffness.

Comprehensive Arthroscopic Shoulder Stabilization in the Lateral Decubitus Position

Arthroscopic shoulder stabilization offers a safe and effective means for restoring glenohumeral mechanics in the setting of shoulder instability. Modern arthroscopic techniques have allowed improved access and efficiency when treating patients with shoulder instability. However, access to certain areas of the labrum and the creation of safe accessory portals can still prove difficult for the arthroscopic surgeon. Currently, there is debate as to the ideal patient position, portal location, equipment, and technique for addressing anterior-inferior labral pathology. The following article presents a safe and effective approach to accessing the labrum for treatment of shoulder instability in the lateral decubitus position. In addition, this paper highlights the use of accessory portals, including a percutaneous "7-o'clock" portal for suture anchor placement, along with multiple types of suture anchor and suture shuttling techniques.

Inter-surgeon variability in the identification of clock face landmarks when placing suture anchors in arthroscopic Bankart repair

BACKGROUND

The accuracy of surgeons in utilizing the clock face method for anchor placement has never been investigated. Our hypothesis was that shoulder arthroscopy surgeons would be able to place suture anchors at predetermined positions with accuracy and reliability.

METHODS

Ten cadaveric shoulders were used. Five fellowship-trained shoulder arthroscopy surgeons were directed to place a suture anchor at 3:30, 4:30, and 5:30 clock in two shoulders each. The position of the anchors was determined with computed tomography. The accuracy of placement was calculated and data analyzed with one-way analysis of variance. The intraclass correlation coefficients were calculated.

RESULTS

The overall accuracy was 57%. The accuracy of anchor placement at the 3:30 position was 40% (average position 2:24 o'clock), it was 50% at the 4:30 position (average position 3:42 o'clock) and 80% at the 5:30 position (average position 5:03 o'clock). No statistical difference in accuracy between the placement of the superior, middle, and inferior anchors (p = 0.145) was seen. The intraclass correlation coefficient for inter-surgeon reliability was 0.4 (fair) while the intraclass correlation coefficient for intra-surgeon reliability was 0.6 (moderate).

DISCUSSION

The findings of this study suggest a moderate degree of accuracy and fair to moderate inter- and intra-surgeon reliability when using the clock face system to guide anchor placement.

Diagnostic Shoulder Arthroscopy: Surgical Technique

Shoulder arthroscopy is the second most common orthopaedic procedure. Diagnostic arthroscopy of the shoulder requires an efficient and reproducible technique. In this Technical Note, we describe a step-wise approach to diagnostic arthroscopy of the shoulder. This technique is performed using a posterior viewing portal. It can be performed from the beach chair or the lateral decubitus position. This technique uses a 2-circle approach: the surgeon first evaluates the glenoid aspect of the joint space, followed by the humeral aspect of the joint space. This method ensures a complete and consistent evaluation of the glenohumeral joint.

Posterior Shoulder Instability

Posterior shoulder instability is a relatively uncommon condition, occurring in ∼10% of those with shoulder instability. Because of the rarity of the condition and the lack of knowledge in treatment, it is often misdiagnosed or patients experience a delay in diagnosis. Posterior instability typically affects athletes participating in contact or overhead sports and is usually the result of repetitive microtrauma or blunt force with the shoulder in the provocative position of flexion, adduction, and internal rotation, leading to recurrent subluxation events. Acute traumatic posterior dislocations are rare injuries with an incidence rate of 1.1 per 100,000 person years. This rate is ∼20 times lower than that of anterior shoulder dislocations. Risk factors for recurrent instability are: (1) age below 40 at time of first instability; (2) dislocation during a seizure; (3) a large reverse Hill-Sachs lesion; and (4) glenoid retroversion. A firm understanding of the pathoanatomy, along with pertinent clinical and diagnostic modalities is required to accurately diagnosis and manage this condition.

The "Floating Labrum": Bankart Lesion Repair With Anterior Capsular Extension Using 2 Anterior Working Portals

Surgical repair of a Bankart lesion requires thorough recognition of the capsulolabral attachment and adequate visualization for suture anchor repair. The glenoid labrum usually detaches from its capsule and bony attachment anteriorly and inferiorly; however, the labral and capsule detachment can sometimes extend beyond this zone of injury. Identification and repair may require additional viewing and working portals to allow for ease of suture passage and anchor placement. This technique guide describes a case scenario of a Bankart lesion with anterior extension of the capsular tear, repaired with use of 2 anterior working portals.

Comprehensive Arthroscopic Management of Glenohumeral Osteoarthritis: Preoperative Factors Predictive of Treatment Failure

BACKGROUND

Patient selection is critical when choosing between arthroscopic joint preservation and total shoulder arthroplasty in young patients with glenohumeral osteoarthritis (GHOA).

PURPOSE

To identify prognostic factors predictive of early failure in patients undergoing comprehensive arthroscopic management (CAM) for GHOA.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 107 shoulders in 98 patients with minimum 2-year follow-up who underwent CAM were identified and evaluated. All shoulders met clinical and radiographic criteria for total shoulder arthroplasty (TSA), but the patients opted for joint preservation with arthroscopic management. Radiographic and preoperative factors were analyzed to determine predictors of early failure, defined as progression to TSA within the study period.

RESULTS

There were 72 men and 26 women with a mean age of 52 years (range, 29-77 years). Seventeen (15.8%) of 107 shoulders progressed to TSA at a mean of 2 years (range, 0.46-8.2 years). Shoulder status for the rest had a mean follow-up of 3.9 years (range, 2-9.4 years). There were a number of radiographic features that were correlated with early failure. Patients who failed had significantly less preoperative joint space than did those who succeeded (1.3 vs 2.6 mm; P = .004). Higher Kellgren-Lawrence grades for osteoarthritis and age older than 50 were also associated with failure. Shoulders with Walch type B2 and C glenoid were significantly more likely to fail than were Walch types A1, A2, and B1 ( P < .05).

CONCLUSION

The CAM procedure has been shown to reliably improve pain and function in active patients with advanced GHOA; however, it is important to inform patients about the limitations of the procedure. Patients with less joint space and abnormal posterior glenoid shape were significantly more likely to progress to early failure.

Using a Posterolateral Portal to Pass and Tie the Suture of the Inferior Anchor During Arthroscopic Bankart Repair

Using a posterolateral portal in passing and tying the inferior knot allows good labral reduction and adequate capsular shift to treat anterior shoulder instability. In this technique, the most inferior anchor is placed through a low anterolateral portal. A penetrating grasper is introduced from a posterolateral portal situated 2 to 3 cm distal and lateral to the viewing portal. This portal is used to pass the 2 limbs of the anchor suture as inferior as possible through the labrum and capsule close to 6 o'clock position to form the 2 limbs of the first mattress suture. Finally, knot tying is performed through this posterolateral portal, thus allowing better superior shift of the capsulolabral tissue. The other 2 anchor sutures are passed and tied through the low anterolateral portal.

The Use of Accessory Portals in Bankart Repair With Posterior Extension in the Lateral Decubitus Position

The Bankart lesion, in which the anteroinferior labrum is detached from the glenoid, is the critical anatomic lesion in the majority of patients with anterior glenohumeral instability. Some patients with anterior glenohumeral instability will have Bankart lesions with posterior extension beyond the 6-o'clock position, and achieving anatomic labral repair in these cases can present a technical challenge. In our experience, the lateral decubitus position and use of accessory portals allow superior visualization of the inferior half of the glenohumeral joint for glenoid and labral preparation, anchor placement, and suture management. The use of double-loaded suture anchors at the inferior glenoid provides multiple points of fixation at this challenging location while limiting the number of anchors required. The purpose of this article is to present a simple and reproducible technique for arthroscopic repair of Bankart lesions with posterior extension, emphasizing the use of accessory 5-o'clock trans-subscapularis and 7-o'clock portals.

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.

Arthroscopic Reduction and Internal Fixation of an Inferior Glenoid Fracture With Scapular Extension (Ideberg V)

Arthroscopic reduction and internal fixation of glenoid fractures have been well described, especially for glenoid rim (Bankart) fractures, as well as for scapular body fractures with extensions into the articular surface. This approach has the advantage of decreasing comorbidities associated with a standard open approach, but it can be technically challenging and may not be amenable to all fracture patterns. Arthroscopic fixation of scapular fractures incorporating a transverse pattern along the inferior aspect of the glenoid is particularly challenging because of difficulty in accessing this space. We detail the use of a posteroinferior arthroscopic portal for fracture reduction and hardware placement in a scapular fracture with inferior glenoid involvement.

Shoulder arthroscopy: the basics

Shoulder arthroscopy is a commonly performed and accepted procedure for a wide variety of pathologies. Surgeon experience, patient positioning, knowledge of surgical anatomy, proper portal placement, and proper use of instrumentation can improve technical success and minimize complication risks. This article details the surgical anatomy, indications, patient positioning, portal placement, instrumentation, and complications for basic shoulder arthroscopy.

Glenoid Rim Anatomy: Risk for Glenoid Vault Perforation During Labral Repair

Background:

Injuries to the glenoid labrum frequently require repair with anchors. Placing anchor devices arthroscopically can be challenging, and anchor malpositioning can complicate surgical outcomes.

Purpose:

To determine the safe insertion range and optimal insertion angle of glenoid labral anchors at various positions on the glenoid rim and to establish surgical guidelines that minimize risk of anchor perforation.

Study Design:

Descriptive laboratory study.

Methods:

Three-dimensional computed tomography scans of 30 normal cadaveric specimens were obtained. A virtual model of a generic labral anchor was inserted into the rim of the glenoid at the clockface positions represented by 12:00, 1:30, 3:00, 4:30, 6:00, 7:30, 9:00, and 10:30. At each position, the safe insertion range was the maximal range measured, and the optimal insertion angle was identified as the angle between the bisector of the safe insertion range and the glenoid face.

Results:

Progressing in the clockwise direction, beginning at the 12:00 position, the safe insertion ranges (mean ± SD ) were 55.9° ± 10.6°, 63.6° ± 17.6°, 47.7° ± 9.1°, 46.1° ± 8°, 73.9° ± 9.7°, 40.9° ± 6.5°, 40.4° ± 7.4°, and 39.9° ± 7.1°, respectively. The optimal insertion angles were 47.9° ± 7.6°, 53.1° ± 10.9°, 35.0° ± 4.4°, 42.4° ± 4.9°, 60.9° ± 8.4°, 36.6° ± 5.9°, 31.2° ± 4.9°, 34.8° ± 4.6°, respectively.

Conclusion:

Optimal insertion angles and safe insertion ranges varied significantly with respect to the position on the glenoid face. The safe insertion range and optimal insertion angle were found to be wider at the anterior glenoid as compared with the posterior glenoid. A posterolateral insertion angle was safer than an anterior insertion angle at the 10:30 position.

Clinical Relevance:

Proper arthroscopic technique resulting in anchor insertion at the correct angle, depth, and location will prevent anchor-related glenohumeral complications such as glenoid perforation, cartilage damage, persistent pain, decreased range of motion, and failure of the reconstruction.

Complications of shoulder arthroscopy

Over the past 20 to 30 years, arthroscopic shoulder techniques have become increasingly popular. Although these techniques have several advantages over open surgery, surgical complications are no less prevalent or devastating than those associated with open techniques. Some of the complications associated with arthroscopic shoulder surgery include recurrent instability, soft-tissue injury, and neurapraxia. These complications can be minimized with thoughtful consideration of the surgical indications, careful patient selection and positioning, and a thorough knowledge of the shoulder anatomy. Deep infection following arthroscopic shoulder surgery is rare; however, the shoulder is particularly susceptible to Propionibacterium acnes infection, which is mildly virulent and has a benign presentation. The surgeon must maintain a high index of suspicion for this infection. Thromboemoblic complications associated with arthroscopic shoulder techniques are also rare, and studies have shown that pharmacologic prophylaxis has minimal efficacy in preventing these complications. Because high-quality studies on the subject are lacking, minimal evidence is available to suggest strategies for prevention.

Arthroscopic bankart repair: accessory posterior portal with slotted cannula for lowest capsulolabral access

We present a novel technique for safe establishment of the accessory posterior portal using a slotted cannula. Arthroscopic Bankart repair is a common procedure. A variety of arthroscopic techniques have been described in the literature, commonly using the posterior portal for visualization and the anterior portal with a working cannula. The accessory posterior portal enables elegant access to the lower part of the capsulolabral junction, a firmer grasp and mobilization of the tissue, quick and easy tool exchange using a slotted cannula, and clearer suture placement because of the flat, direct working angle. The skin incision is made small without the need for an arthroscopic cannula, and the portal location is in a relatively safe zone. The use of the accessory posterior portal along with a slotted cannula shortens the duration of the operative procedure and improves safety and performance.

The global percutaneous shuttling technique tip for arthroscopic rotator cuff repair

Most arthroscopic rotator cuff repairs utilize suture passing devices placed through arthroscopic cannulas. These devices are limited by the size of the passing device where the suture is passed through the tendon. An alternative technique has been used in the senior author’s practice for the past ten years, where sutures are placed through the rotator cuff tendon using percutaneous passing devices. This technique, dubbed the global percutaneous shuttling technique of rotator cuff repair, affords the placement of sutures from nearly any angle and location in the shoulder, and has the potential advantage of larger suture bites through the tendon edge. These advantages may increase the area of tendon available to compress to the rotator cuff footprint and improve tendon healing and outcomes. The aim of this study is to describe the global percutaneous shuttling (GPS) technique and report our results using this method. The GPS technique can be used for any full thickness rotator cuff tear and is particularly useful for massive cuff tears with poor tissue quality. We recently followed up 22 patients with an average follow up of 32 months to validate its usefulness. American Shoulder and Elbow Surgeons scores improved significantly from 37 preoperatively to 90 postoperatively (P<0.0001). This data supports the use of the GPS technique for arthroscopic rotator cuff repair. Further biomechanical studies are currently being performed to assess the improvements in tendon footprint area with this technique.

The posterolateral portal: optimizing anchor placement and labral repair at the inferior glenoid

The Bankart lesion is considered the critical lesion in anterior shoulder instability, in which the anteroinferior glenoid labrum separates from the glenoid rim. Technical advances in arthroscopy have ushered in a shift from open to arthroscopic Bankart repair. When one is performing an arthroscopic Bankart repair, proper portal placement is critical for success in labral preparation and anchor placement. Frequently, standard anterior portals are insufficient for inferior glenoid anchor placement and suture shuttling. The posterolateral portal-located 4 cm lateral to the posterolateral corner of the acromion-simplifies and improves anchor placement, trajectory, and anatomic capsulolabral repair of the inferior glenoid. We present our preferred technique for capsulolabral repair of the inferior glenoid.

Inferior anchor cortical perforation with arthroscopic Bankart repair: a cadaveric study

PURPOSE

The aims of this study were to evaluate the incidence of anchor penetration of the far cortex of the glenoid neck after arthroscopic Bankart repair and to compare the biomechanical properties of anchors in the 4- and 5:30- to 6-o'clock positions on the glenoid.

METHODS

Twelve (6 matched pairs) fresh-frozen human cadaveric shoulders were used to simulate arthroscopic Bankart repair in the lateral decubitus position. The most inferior anchor (5:30 to 6 o'clock) and that above it (4 o'clock) were inserted via the anteroinferior portal on the glenoid using the standard technique. After both anchor insertions, anchor perforation of the glenoid far cortex was identified. Biomechanical properties were measured to determine cyclic displacement of anchors at 100 and 500 cycles, stiffness, yield load, and ultimate failure strength.

RESULTS

All 12 suture anchors (100%) at 5:30 to 6 o'clock penetrated throughout the far cortex, whereas only 4 anchors (33%) at 4 o'clock did so (P = .005). The mean distance the anchor tip traveled into far cortex was significantly longer at 5:30 to 6 o'clock than at 4 o'clock (6.8 ± 1.6 mm v 2.0 ± 1.6 mm, P = .001). In terms of mechanical strength, anchors at 5:30 to 6 o'clock had greater 100- and 500-cycle mean displacements than those at 4 o'clock (3.0 ± 0.5 mm v 2.5 ± 0.3 mm, P = .018 for 100 cycles; 3.5 ± 0.7 mm v 2.8 ± 0.3 mm, P = .018 for 500 cycles), although no differences in ultimate failure strength after cyclic loading were found between 2 positions (133.4 ± 40.3 and 133.7 ± 29.2 N, respectively; P = .985).

CONCLUSIONS

For arthroscopic Bankart repair, insertion of the most inferior anchor via the anteroinferior portal with standard technique, in the lateral decubitus position, carries a high risk of perforating the inferior far cortex of the glenoid (100% in our study). This may result in mechanical weakness of the most inferior repair specifically in the early postoperative period.

CLINICAL RELEVANCE

Perforation of the glenoid far cortex by the most inferior anchor and its mechanical weakness should be taken into consideration. Further study is needed to improve surgical technique to place the most inferior anchor in an optimal position by arthroscopy.

Humeral avulsion of glenohumeral ligaments

Humeral avulsion of glenohumeral ligaments (HAGL) is an increasingly recognized cause of recurrent shoulder instability. HAGL lesions are the result of acute traumatic glenohumeral subluxation or dislocation. Anterior avulsion of the inferior glenohumeral ligament from the humeral neck is the more common lesion; however, posterior lesions are seen as well. Careful history and physical examination are critical in the diagnosis of HAGL lesions. MRI is the best imaging study for diagnosing these lesions. Injection of intra-articular contrast dye aids in visualization. Most HAGL lesions cause recurrent instability and require surgical repair. Arthroscopic repair with the use of accessory portals has yielded promising results. Excellent results have been achieved with open surgical management using a subscapularis incision. Mini-open techniques involve limited incision in the lower one half of the subscapularis.

Arthroscopic management of posterior instability

In comparison with anterior shoulder instability, posterior instability is uncommon, occurring in 2% to 10% of cases, and covering a wide clinical spectrum ranging from locked posterior dislocation to the often subclinical recurrent posterior subluxation (RPS). With increased clinical awareness, imaging advances such as magnetic resonance arthrography, and the development of specific provocative physical examination tests, the identification of RPS in the athletic population is improving. This article describes the anatomic-based arthroscopic approach to treatment of RPS, which allows for enhanced identification and repair of intra-articular pathology including posterior capsular laxity, complete or incomplete detachment of the posterior capsulolabral complex, and inferior capsular tears. While postoperative results are generally good to excellent after stabilization for RPS, there is room for improvement.

Four-quadrant approach to capsulolabral repair: an arthroscopic road map to the glenoid

Advancing technology, improved instrumentation, and a desire to address intra-articular pathology with a minimally invasive approach have driven the expansion of arthroscopic shoulder surgery in the past 2 decades. Proponents cite greatly improved visualization, lack of the need to perform a capsulotomy, fewer subscapularis issues postoperatively, and improved access to the entire glenohumeral joint. Our understanding and recognition of glenohumeral joint pathology have improved, and our ability to appropriately treat it has also improved. Aside from the anteroinferior and superior capsulolabral injury, orthopaedic surgeons have encountered and are able to address combined lesions, posterior labral tears, 270 degrees to 360 degrees labral tears, capsular laxity, humeral avulsion of the glenohumeral ligaments, associated glenoid or humeral bone loss, and partial-thickness rotator cuff tears. To adequately address the extent of pathology encountered in a shoulder instability case, access to the inferior, posteroinferior, and posterior aspects is necessary. In this technical article we present a simplified approach using safe access points by dividing the glenohumeral joint into 4 quadrants that allows for ease of instrumentation and implant placement. This will provide a blueprint for the treatment of capsulolabral injuries. In addition to portal selection and location, we will discuss several instruments we believe are advantageous in tissue manipulation and suture management.

Combined arthroscopic repair of a type IV SLAP tear and Bankart lesion

Lesions of the superior labrum can be a source of significant shoulder pain and disability. SLAP (superior labrum anterior-posterior) tears have been classified into many different types. A type IV SLAP tear is a bucket-handle tear of the superior labrum with extension into the biceps tendon. This relatively uncommon SLAP tear, if present, has been shown to be frequently associated with other pathology including Bankart lesions. We present an arthroscopic technique for combined repair of a type IV SLAP tear and Bankart lesion. Steps include initial reduction of the bucket-handle portion of the superior labral injury, repair of the anterior-inferior labral detachment, and, finally, repair of the superior labrum and biceps tendon split.

Synovial fold of the posterior shoulder joint capsule

PURPOSE

The purpose of the study is to describe, based on shoulder MRI and MR arthrography with arthroscopic correlation, a posterior joint capsule fold.

MATERIALS AND METHODS

A retrospective review of 410 shoulder MRIs and direct MR arthrograms with arthroscopic correlation in positive cases (when available) was obtained with IRB approval and HIPPA compliance. The study was performed by three musculoskeletal radiologists. The criteria utilized to establish the diagnosis of posterior synovial fold included: (1) axial T1-weighted (T1W) on MR arthrography or axial T2* GRE-weighted on MRI demonstrating rounded thickening of the posterior shoulder joint capsule with a thickness at least 2 mm in diameter. (2) The posterior synovial fold extends in an oblique craniocaudal direction from the posterior-inferior joint capsule adjacent to the posterior-inferior glenoid labrum (7 o'clock) and continues superiorly away from the glenoid labrum to the posterior-superior joint capsule (11 o'clock).

RESULTS

Although uncommon, the posterior synovial fold was present in 2% (8/410) of studies reviewed and found predominantly in women (75%, 6/8). Four patients had arthroscopic confirmation of the posterior synovial fold. A higher percentage of posterior synovial folds were observed on shoulder MR arthrography (2.7%, 4/150) than on shoulder MRI (1.5%, 4/260).

CONCLUSION

Although rare, the posterior synovial fold can be recognized and should not be confused with a posterior labral tear. Further investigation is needed to assess its histologic properties and its clinical significance.

Arthroscopic management of posterior shoulder instability: diagnosis, indications, and technique

With increased understanding of the different patterns of posterior shoulder instability, diagnostic acumen and successful treatment algorithms have evolved. Improvements in imaging and advancements in arthroscopic surgical techniques have facilitated this progress. In athletic populations, recurrent posterior subluxations (RPSs) are far more common than recurrent or locked posterior dislocations. Conservative and operative management of posterior instability is individualized to meet the demands of its diverse patient population, ranging from post-traumatic instability in contact athletes to RPSs in overhead athletes.

Humeral avulsion of the glenohumeral ligament: injury pattern and arthroscopic repair techniques

The arthroscopic treatment of a humeral avulsion of the glenohumeral ligaments lesion allows for a safe, reproducible, and effective way to reestablish the inferior glenohumeral ligament and capsular complex to the humerus.

An anatomic study of inferior glenohumeral recess portals: comparative anatomy at risk

PURPOSE

The purpose of this study was to describe the musculotendinous relations and neurologic structures at risk during establishment of posterior portals for access to the inferior glenohumeral recess (IGHR).

METHODS

Three 18-gauge spinal needles were used to establish 2 posteroinferior portals and 1 axillary pouch portal in 14 embalmed cadaveric shoulders, without joint distention and arthroscopic visualization. At dissection, musculotendinous structures traversed by the needles were recorded, and distances from the (1) axillary nerve (at the deltoid undersurface, quadrangular space, and capsule), (2) nerve to teres minor (at the inferior border of the teres minor muscle and at the capsule), and (3) suprascapular nerve were measured. Additional parameters studied included the vertical distances between the acromion and IGHR and between the acromion and axillary nerve. Statistical analysis (multiple comparisons procedure) was performed to compare relative portal safety.

RESULTS

The mean distance of the axillary pouch portal to the 3 nerves, at each level, was greater than that of the posteroinferior portals. In 1 specimen (7.1%), the posteroinferior portal tracts were in close proximity (within 2 mm) to the axillary nerve and its branch to the teres minor. The distance of the axillary pouch portal to the nerves was significantly greater (P < .05) at every level, except at the deltoid undersurface.

CONCLUSIONS

Our study suggests that posterior portal techniques described for access to the IGHR are safe; the risk of axillary nerve injury with posteroinferior portals is low, though possible. The axillary pouch portal is relatively farther away from the neurologic structures and provides safer access to the same region.

CLINICAL RELEVANCE

Arthroscopic procedures that require access to the IGHR can be safely performed with posteroinferior and axillary pouch portals. The axillary pouch portal may be used preferentially for this access because it is placed farthest from the neurologic structures.

The axillary pouch portal: a new posterior portal for visualization and instrumentation in the inferior glenohumeral recess

Arthroscopic access to the inferior glenohumeral recess is necessary in several surgical procedures on the shoulder. Posteroinferior portals described for access to this region may pose a theoretic risk to the posterior neurovascular structures (outside-in technique) and to the articular cartilage (inside-out technique). The first author (D.N.B.) has devised a new posterior portal that permits direct linear access to the entire inferior glenohumeral recess. The portal is placed higher and more lateral compared with the previously described portals; this places it further away from the posterior neurovascular structures and facilitates linear access to the axillary pouch. The portal is created via an outside-inside technique, with a spinal needle to ascertain the correct portal site and angulation. The portal is placed at a mean distance of 20.45 +/- 4.9 mm (range, 15 to 35 mm) directly inferior to the lower border of the posterolateral acromial angle and 21.3 +/- 2 mm (range, 20 to 25 mm) lateral to the posterior viewing portal. The spinal needle or cannula is angulated medially at a mean of 30.6 degrees +/- 4.7 degrees (range, 25 degrees to 40 degrees ) in the axial plane and slightly inferiorly (mean, 2 degrees ; range, 20 degrees superiorly to 20 degrees inferiorly). Use of 30 degrees and 70 degrees arthroscopes through the axillary pouch portal facilitates visualization of the entire recess and of the humeral attachment of the inferior glenohumeral ligament complex for evaluation of humeral avulsion of the glenohumeral ligament lesions. The portal also permits instrumentation in combination with the standard posterior or anterosuperior viewing portal for removal of loose bodies, synovectomy, capsular shrinkage, capsulotomy, and anchor placement in the posteroinferior glenoid rim.

Revision arthroscopic shoulder instability repair

PURPOSE

The purpose of this study was to report on a difficult patient population and to critically evaluate the role of revision arthroscopic stabilization surgery.

METHODS

Eighteen patients with failed traumatic instability repairs were treated with revision arthroscopic labral fixation and plication with a mean follow-up of 29.7 months (range, 24 to 48 months). There were 15 male patients and 3 female patients with a mean age of 28.6 years (range, 15 to 50 years). Of the 18 patients, 9 were Workers' Compensation cases. The 18 patients had a mean of 1.55 surgeries before our revision surgery, with 9 having a component of thermocapsular shrinkage. The patients' characteristics, operative techniques, and findings were recorded, and their clinical outcome was critically evaluated (via physical examination, visual analog pain scale, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, and Short Form 12).

RESULTS

The revision surgery incorporated a 4-portal technique via a mean of 4.6 suture anchors and 3 plication stitches, and 15 patients received a rotator interval closure. At the follow-up evaluation, 13 patients had satisfactory results whereas 5 cases were considered clinical failures (with recurrent instability in 3 and pain in 2). There was clinically significant improvement in pain score (6 preoperatively v 2 postoperatively, P = .0001), Simple Shoulder Test score (6 preoperatively v 10 postoperatively, P = .001), and American Shoulder and Elbow Surgeons score (50 preoperatively v 76 postoperatively, P = .001). Of the 9 Workers' Compensation patients, 5 were able to return to their original work.

CONCLUSIONS

Arthroscopic revision instability repair by use of a combination of suture anchors, plication stitches, and rotator interval closure can result in a satisfactory outcome in selected patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The superior-medial shoulder arthroscopy portal is safe

PURPOSE

The superior-medial (SM) shoulder arthroscopic portal (Neviaser portal) is the portal anatomically closest to the suprascapular nerve, and any potential benefits of this portal would be mitigated if risk of suprascapular nerve injury were significant. The purpose of this study is to determine the safety of the SM arthroscopic shoulder portal. We hypothesize that the SM shoulder arthroscopic portal is safe.

METHODS

Twelve fresh cadaveric shoulders were securely positioned to simulate shoulder arthroscopy in the beach-chair position with the arm at the patient's side in neutral rotation. An SM portal was established 1 cm medial to the acromion and 1 cm posterior to the clavicle, and a 5.5-mm burr sheath was oriented toward the acromioclavicular joint. The skin and trapezius were resected, the supraspinatus was retracted, and the suprascapular nerve was identified. The distance between the sheath and the nerve was measured by 2 independent observers with calipers. A safe distance was defined as 10 mm.

RESULTS

The measured distances between the nerve and burr ranged from 18.5 to 35.7 mm, with a mean of 24.2 +/- 5 mm. The distance is significantly greater than the safe distance of 10 mm (P < .0001).

CONCLUSIONS

This study shows that the SM portal is safe. The distance between an instrument oriented toward the acromioclavicular joint via the SM portal and the suprascapular nerve was 18.5 mm or greater in all specimens.

CLINICAL RELEVANCE

Our study has clinical relevance because the SM portal is useful for arthroscopic rotator cuff repair, arthroscopic superior labrum repair, and arthroscopic distal clavicle excision.

The accessory posteromedial portal revisited: utility for arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair is a technically challenging procedure. Accessory arthroscopic portals have been described that allow for optimal suture anchor placement, suture management, and knot tying. We describe here the usefulness of an accessory posteromedial portal that facilitates direct suture retrieval through the posterior aspect of a rotator cuff tear. This portal is created approximately 4 to 5 cm medial to the posterolateral corner of the acromion and 2 cm inferior to the scapular spine. The accessory posteromedial portal is especially useful when a retracted tear of the infraspinatus or teres minor is encountered. Because these tendons retract in a posterior and medial direction, the accessory posteromedial portal places the tendon-penetrating device in an ideal position for suture passage through the posterior portion of the rotator cuff tear. This portal also allows placement of margin convergence sutures for large U-shaped or L-shaped tears by permitting a direct "hand-off" of the suture to or from a second penetrating device that is placed through a standard anterior portal. If multiple suture anchors are required (as in the case of large or massive cuff tears, or when double-row fixation is employed), sutures can be pulled out through the accessory posteromedial portal to facilitate suture management.

Arthroscopic repair of a posterior humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion

Recently, the humeral avulsion of the inferior glenohumeral ligament (HAGL) has been described as a cause of shoulder instability. All documented cases in the literature describe the avulsion as an anterior and lateral disruption leading to anterior instability. We detail a previously unreported case of a HAGL lesion involving the posterior band of the inferior glenohumeral ligament. Arthroscopic reattachment using an additional posteroinferior portal resulted in a successful repair.

Arthroscopic posterior portal closure

Posterior "working" portals in arthroscopic posterior stabilization could result in defects of the posterior capsule if not repaired. We describe a single portal technique used to close the posterior portal defect after arthroscopic stabilization. It is a safe and easy-to-perform technique, which could strengthen the structural integrity of the repair.