Abstract
Background:
The most common technique described for bankart repair is the single-row labral repair. Recent interest has been the use of a dual-row, double pulley technique, first described by Zhang et al and popularized by Millett et al as the “bony Bankart bridge” technique. The aim of this study is to report a double-row all-suture labral fixation technique using knotless anchors.
Technique:
Step 1: glenohumeral debridement, and preparation of the glenoid labral and Bankart. The patient is first placed in the beach-chair position and surface landmarks are created. The standard posterior portal is first created and the glenohumeral joint is evaluated. Once the lesion is identified, the relevant working anterosuperior and anteroinferior portals are established using the outside-in technique. The synovitis is debrided to allow visualization and the labrum is liberated from the anterior glenoid. The Bankart lesion fragment is liberated, and partial fragments are osteotomized. With the anterolateral portal as the viewing portal, the anterior rim of the glenoid is now decorticated using a motorized shaver and rasp to create a bleeding bony surface. Step 2: the low rim anchor (5:30 o’clock). At the anterior-inferior aspect of the glenoid, the drill guide is positioned as low as possible (5:30 o’clock position for the right shoulder) and about 7 to 10 mm medial to the rim of the glenoid. The first 1.8 mm single-loaded suture anchor (Q-FIX All-Suture Anchor) is then inserted via the posterior portal. Step 3: the anterior-inferior-medial (AIM) anchor (4 o’clock). Step 4: the knotless high rim anchor (3 o’clock). Step 5: tying of sutures. The sutures from each anchor are tied in a mattress configuration, eventually creating a suture bridge over the labral repair
Discussion/Conclusion:
This dual row labral repair technique allows for maximum compression and contact between the fragment and the glenoid bed, allowing healing over a contact area rather than just the rim. The other added advantage is the use of curved tip anchors which allow negotiation of difficult corners, especially in the 5 to 6 o’clock position.
This is a visual representation of the abstract.
Video Transcript
We are now presenting arthroscopic repair of a Bankart lesion using the dual-row labral repair.
We have no conflicts of interest to declare.
This is a brief overview of the project. The most common technique described for Bankart repair is the single-row labral repair. Recent interest has been the use of a dual-row, double pulley technique, first described by Zhang et al and popularized by Millett et al as the “bony Bankart bridge” technique. The aim of this study is to report a double-row all-suture labral fixation technique using knotless anchors.
These are the steps of the technique: Step 1: glenohumeral debridement, and preparation of the glenoid labral and Bankart. Step 2: the low rim anchor (5:30 o’clock). Step 3: the anterior-inferior-medial (AIM) anchor (4 o’clock). Step 4: the knotless high rim anchor (3 o’clock). Step 5: tying of sutures to create a suture bridge.
This is a 17-year-old volleyball player who has a history of recurrent shoulder dislocations. The most recent incident occurred 1-month prior while performing a block where his right arm was forced backwards. On examination, he demonstrated signs of shoulder instability as evidenced by a positive anterior apprehension test and a positive load and shift test. A magnetic resonance arthrogram of the shoulder was requested, which showed a torn anterior-inferior labrum with a minimal hill sachs lesion.
After general anesthesia, the patient is placed in an upright beach chair position with the arm free to flex forward and rotate. Examination under anesthesia is first performed on the affected shoulder to assess the degree of instability and capsular laxity. Bony landmarks and portal positions are surface marked as shown.
The posterior portal is first created 1 inch medial to and inferior to the postero-lateral corner of the acromion. From this viewing portal, the glenohumeral joint is evaluated and routine arthroscopic examination is performed, which shows a torn superior and anterior labrum with a loose and patulous anterior capsule. The anterosuperior and anteroinferior portals are established using the outside-in technique. The 5 mm cannulas are then inserted into each portal.
The anterior labrum is first mobilized from the glenoid and any synovitis is debrided sufficiently to allow visualization. The Bankart fragment is liberated and partial fragments are osteotomized. With the anterolateral portal as the viewing portal, the anterior rim of the glenoid is now decorticated using a motorized shaver and rasp to create a bleeding bony surface.
We present the curved Q-FIX Anchor (Q-FIX All-Suture Anchor, Smith & Nephew) that is curved at the knob as shown. At the anterior-inferior aspect of the glenoid, the drill guide is positioned as low as possible (5:30 o’clock position for the right shoulder) and directly at the rim). A 1.8 mm single-loaded suture anchor is then inserted via the anterior-inferior portal. This demonstrates the surgeon deploying the anchor.
A 70° straight suture passer (Acupass, Smith & Nephew) is delivered through the anterior-inferior portal and is used to pierce the capsulolabral complex, incorporating the anterior inferior glenohumeral ligament (IGHL). Using a similar approach, another bite of the capsulolabral complex is taken below the Bankart lesion. The sutures are passed to capture the labrum and IGHL in a mattress configuration. This shows the shuttling of the sutures. This is a side-by-side comparison showing the first low mattress stitch.
At the medial aspect of the glenoid, the drill guide is positioned at the 4 o’clock position for the right shoulder and about 7 to 10 mm medial to the rim of the glenoid. The second 1.8 mm single-loaded suture anchor (Q-FIX All-Suture Anchor) is then inserted via the anterior-inferior portal.
A grasper is inserted through the anterosuperior portal to tent the anteroinferior labral complex. At the same time, a straight suture passer is used to pierce the capsulolabral complex. Sutures from the AIM anchor are passed in the second mattress configuration.
One suture limb from each pair are tied together to create a horizontal tie over the AIM anchor.
This video shows a pair of sutures (A) and (B) being tied to a knotless anchor (Micro-Raptor, Smith & Nephew). The knotless anchor is directed at the 3 o’clock position. The remaining sutures are tied to the high rim anchor at the 3 o’clock position, creating a suture bridge over the labral repair. The final repair is checked at the end of the surgery. Here is a simple graphic representation showing how we perform the technique.
Postoperatively, all patients are placed in a gunslinger brace and started on pendulum exercises in the immediate postoperative period. The brace is discontinued at 4 weeks and active shoulder range of motion is started. Strengthening exercises are started 2 to 3 months after surgery. Patients are permitted to return to sporting activities at 4 to 6 months of rehabilitation after they have achieved full range of motion and enough strength.
These are some of the pitfalls and pearls of the technique: (1) Always view the anterior labrum from 2 portals alternately, from the posterior portal and the anterolateral portal. This will help visualize the labrum with orthogonal perspective. (2) Debride and mobilize the labrum well. The anterior IGHL must be able to be tented up, to be incorporated into the repair. (3) The first pair of sutures must incorporate both the labrum and anterior IGHL and spaced about 7 to 10 mm apart from each other. (4) The remaining pair of sutures are secured to a knotless anchor at the 3 o’clock position (the high rim anchor) while ensuring there is a good and adequate shift of the IGHL and capsule.
As for the pitfalls: (1) Getting the low rim anchor low enough at the 5 to 6 o’clock position can be tricky without the use of a curved guide and anchor. A straight guide and anchor can easily skive off the inferior glenoid. (2) Similarly, the anteroinferior medial anchor at the 4 o’clock position about 5 to 7 mm medial to the glenoid rim is best placed using a curved guide and anchor. A straight guide and anchor can skive off the anterior glenoid vault. (3) As the horizontal tie between the 2 pairs of sutures is secured, keep the arm in neutral position with the forearm pointing forwards. If the shoulder is in internal rotation, the soft tissue plication may be too tight.
These are some of the factors that make a good repair: (1) a strong suture configuration that gives tension to capsular shift and compression on labral repair; (2) a strong and robust labral repair; (3) a solid capsular shift to obliterate the anterior space and create an anterior wall; (4) an anatomical surface area for the labral to heal to.
Restoration of the normal glenoid rim is crucial to addressing the anterior instability. The most common procedure for a Bankart repair is the single row labral repair. However, a major complication of this is the recurrence of instability.
A cadaveric study by Ahmad et al found that the single row repair recreated 42.3% of the native surface area of the capsulolabral complex footprint while the double row repair recreated 85.9%.
The dual-row labral repair has been extensively used for bony Bankart lesions, allowing healing of the capsulolabral complex over a surface area and reducing the rates of recurrent shoulder instability.
The current evidence for dual-row labral repair in Bankart lesions has also shown to decrease the incidence of retear.
The authors of this study believe the technique described above will allow labral healing over a surface area between the anchors, rather than a point fixation. Current clinical and biomechanical studies are ongoing to further evaluate this.
Here are the references.
We have now come to the end of the presentation. Thank you.
Footnotes
Submitted February 8, 2021; accepted April 11, 2021.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.