Arthroscopic Bankart Repair for Anterior Shoulder Instability Using a Posterolateral Portal
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Procedure Outline
Table of Contents
- Interscalene regional nerve block given in the preoperative holding area
- General anesthesia given in the Operating Room
- Place the patient in the lateral decubitus position
- Ensure that all bony prominences are padded
- The shoulder is then placed in 40 degrees of abduction, 20 degrees of forward flexion, and 10-15 pounds of balanced traction
- The shoulder is prepped and draped in the usual sterile fashion
- The glenohumeral joint is first injected (posteriorly) with 50 mL of sterile saline through an 18-gauge spinal needle. Alternatively, the soft spot is identified in thinner patients and can be a relatively easy access point for entry in the absence of saline insufflation.
- A posterior portal is established 1 cm distal and 1 cm lateral to the standard posterior portal that is used for routine shoulder arthroscopy.
- This portal is often in line with the lateral border of the acromion.
- Placement of this portal more laterally than typical allows adequate access to the posterior glenoid rim for later anchor placement.
- An anterior portal is established high in the rotator interval via an inside-out technique with a switching stick.
- As an alternative, this portal can be established with a spinal needle via an outside-in technique.
- The anterior switching stick is then replaced with a 7mm distally threaded clear cannula.
- Through the posterior portal, a diagnostic arthroscopy is performed.
- The articular surfaces of the glenohumeral joint are inspected for chondral damage.
- The posterolateral aspect of the humeral head is inspected for any Hill-Sachs lesions (which may indicate combined anterior instability).
- The anterior and inferior labrum is inspected and the glenohumeral ligaments are visualized. The biceps tendon and superior labrum are probed to detect any pathology.
- Concomitant SLAP tears are common with posterior instability.
- The rotator cuff is inspected (including the subscapularis tendon).
- A switching stick is then placed in the posterior portal and replaced with an additional 7mm distally threaded clear cannula.
- The arthroscope is then replaced into the anterior cannula for viewing; it remains there for the rest of the operation.
- The posterior capsule and labrum are inspected and probed.
- The anterior humeral head surface is inspected for any reverse Hill-Sachs lesions, which may indicate macroinstability.
- Typically the posterior labrum is detached and the capsule attenuated, requiring the placement of suture anchors.
- An arthroscopic rasp or chisel is used to mobilize the labrum from the glenoid rim.
- The rasp is then used to debride the capsule to create an optimal environment for healing.
- A motorized shaver or burr can be used on the glenoid rim to achieve a bleeding surface for healing.
- An arthroscopic rasp or chisel is used to mobilize the labrum from the glenoid rim.
- The rasp is then used to debride the capsule to create an optimal environment for healing.
- A motorized shaver or burr can be used on the glenoid rim to achieve a bleeding surface for healing.
- Suture anchors are placed along the articular margin, not the glenoid neck, for the repair and capsular plication.
- Typically we use three 2.3mm Bio-Raptor suture anchors with no. 2 Ultrabraid (Smith and Nephew, Andover, MA). A number of other commercially available anchors can be used in a similar fashion.
- The anchor pilot holes are predrilled and the anchor is inserted with a mallet.
- The anchor is placed so that the sutures are perpendicular to the glenoid rim. This facilitates passage of the most posterior suture through the torn labrum.
- The anchors are evenly spaced on the posterior glenoid rim for a symmetric repair.
- A 45 degree Spectrum Hook (Linvatec Corp., Largo, FL) loaded with number 0 PDS suture (Ethicon, Somerville, NJ) is used to shuttle the suture through the capsule and labrum.
- The suture hook is delivered through the capsule (if a plication is warranted) and under the torn labrum at the articular margin of the glenoid.
- An inferior-to-superior direction is used for this maneuver to achieve a small capsular plication.
- This direction of suture passage is aimed at restoring tension to the posterior band of the inferior glenohumeral ligament.
- Patients with significant instability clinically may require a more aggressive plication than those with isolated pathology to the glenoid labrum.
- The PDS is fed into the glenohumeral joint and the passer is withdrawn.
- A suture grasper is then used to withdraw the most posterior suture in the anchor and the PDS that has been delivered through the capsulolabral complex.
- Grabbing the more posterior suture helps to ensure that the suture limbs do not become entangled.
- The PDS is then fashioned into a single loop and tied over the braided Ultrabraid suture.
- The opposite limb of the PDS is then pulled and the Ultrabraid is delivered through the labrum and capsule.
- Additional sutures are then shuttled in similar fashion to complete the repair.
- After each suture has been shuttled through the capsular-labral complex, it is tied using arthroscopic knot tying techniques.
- Note: We prefer to begin our repair inferiorly and advance superiorly up the posterior glenoid rim. In this way, the tension achieved with each advancing stitch can be assessed.
- An arthroscopic awl is used to penetrate the posterior bare area of the humerus in an effort to achieve punctate bleeding to augment the healing response.
- The posterior cannula is then withdrawn to just posterior to the level of the capsule and the posterior capsular incision is closed with a PDS suture.
- A crescent Spectrum suture passer is used to penetrate one side of the capsule by the posterior capsular incision, and the suture is threaded into the joint.
- The suture is retrieved through the opposite side of the incision with a penetrator and an arthroscopic knot is tied down to close the portal.
- Varying the distance of the suture from the portal incision allows additional tension to be applied to the posterior capsule.
- Inspect the integrity of the repair.
- If additional plication is warranted (such as in multidirectional instability), additional sutures can be placed in the rotator interval or anterior capsule as described elsewhere in this text.
- The skin portals are closed with interrupted nylon suture and the patient is placed in a sling that allows slight abduction.
