Arthroscopic Anterior Labral Repair With Capsulorrhaphy and Interval Closure: Surgical Technique

Abstract

Background:

Traumatic anterior labral injuries (Bankart lesions) lead to anterior shoulder instability. Arthroscopic anterior labral repair (also known as Bankart repair) provides a soft tissue reconstruction to reduce the risk of dislocation. However, the described techniques vary significantly. We present our technique for enhancing the quality and volume of tissue incorporated in the repair and utilizing interval closure to further reduce recurrent instability rates.

Indications:

Non-throwing athletes or high-demand patients with recurrent instability after a traumatic event with <20% glenoid bone loss. This can include young patients (<25 years) who are first-time dislocation patients participating in high-risk sports.

Technique:

Shoulder arthroscopy is performed in the lateral position with a standard posterior portal and 2 anterior portals. While viewing from the posterior portal and working from the anterosuperior portal, the labral and capsular tissues are completely elevated from the anterior and inferior glenoid. The native labral footprint on the glenoid is prepared for repair using a hooded bur. Sutures are passed through the capsulolabral tissue with a self-retrieving device. The first suture is passed into the inferior labral tissue from the anteroinferior portal. In contrast, subsequent suture passages along the anterior glenoid are performed from the posterior portal, all while viewing from the anterosuperior portal. The tissue is then sequentially advanced into the knotless anchors along the anterior face of the glenoid, creating a robust soft tissue restraint to glenohumeral instability. An arthroscopic rotator interval closure is then performed for further stability.

Results:

A review of this procedure in 38 active patients with at least 2 years of follow-up demonstrated an improved outcome score, with a 10.5% rate of redislocation. Two shoulders underwent revision surgery for recurrent instability.

Discussion/Conclusion:

Arthroscopic anterior labral repair with capsulorrhaphy and interval closure effectively reduces recurrent anterior shoulder instability. This video demonstrates techniques for enhancing the quality and quantity of soft tissue incorporated into the repair.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) have included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

We present our surgical technique for arthroscopic anterior labral repair (Bankart repair) with capsular shift and interval closure, as described by Drs Vishal Desai and John Kopriva, Benjamin King, and Camryn Petit, under the guidance of senior author Dr Spero Karas, from Emory University in Atlanta, Georgia.

In this presentation, we provide a brief review of Bankart injuries and shoulder instability, using a specific case presentation as an example. We discuss treatment considerations and the decision to proceed with an arthroscopic soft tissue procedure. We discuss our preferred surgical technique and review technical pearls. Finally, we discuss our postoperative protocol and patient outcomes data.

Background

Shoulder instability is a common condition, often accompanied by high recurrence rates.^9-14 Traumatic instability typically results in labral injury and can include bony lesions on the glenoid and humerus.^9,11

For soft tissue injuries, arthroscopic Bankart repair has become the standard of care, as it has been shown to decrease the rate of recurrent instability.^{1-6, 8-11}

Indications

This is a 17-year-old male high school football athlete, a linebacker, who sustained a first-time left shoulder anterior dislocation while tackling during a game. Closed reduction was performed on the field. After 6 weeks of physical therapy and rehabilitation efforts, the patient returned to sport with a sully brace. Despite reporting improvements in the strength and motion of his left shoulder, the patient continued to experience instability and apprehension, which limited his ability to compete.

Upon examination, the patient was neurovascularly intact and demonstrated excellent shoulder strength and motion. However, the patient did have a positive load and shift test and a positive apprehension-relocation test.

In-office radiographs demonstrated a concentric joint with no appreciable osseous abnormalities. Subsequent magnetic resonance imaging confirmed an anterior-to-inferior labral tear. A small, subcritical glenoid cartilage defect was identified anteriorly. No significant Hill-Sachs deformity was present.

The patient elected to proceed with arthroscopic Bankart repair.

Technique Description

Here, we demonstrate a preoperative examination under anesthesia with the Hawkins grade 2+ translation and a sulcus that persisted in external rotation.

For arthroscopic shoulder instability procedures, we prefer the lateral position. The operative arm is placed in 15 lbs of traction, and supplementary lateralizing traction is placed proximally on the arm adjacent to the axilla.

A standard posterior portal is established, keeping in mind that a gentle lateral to medial trajectory is preferred, as this will also act as a working portal with instruments crossing the glenoid later in the case.

A 6-mm cannula is placed in the anterior superior portal, and a larger 8.25-mm cannula is placed in the anterior inferior portal.

Diagnostic arthroscopy is then performed, which confirms an anterior inferior labral injury.

The camera is then moved to the anterior superior portal, while leaving the inflow in the posterior portal. Here, we demonstrate the appropriate trajectory of the posterior portal to access the anterior labrum.

A liberator knife is used to elevate the injured labrum from the glenoid. This is taken just past the 6 o'clock position to allow for better capsular advancement and incorporation of the posterior band of the inferior glenohumeral ligament (IGHL).

Electrocautery is used to further elevate the labral and capsular tissues, reaching the 6 o'clock position. It is then used to create a landing zone on the anterior glenoid face, typically no wider than the 4-mm tip.

This surface is then gently prepped using a 5-mm hooded bur, taking care to protect the labral tissue.

For the first suture passage, a self-retrieving device is inserted through the anterior inferior portal, passing a nonabsorbable suture through a substantial segment of tissue. The intent is to obtain tissue posterior to the 6 o'clock position, thus integrating the posterior band of the IGHL.

For subsequent passes, the self-retrieving device is switched to the posterior portal. This allows for the efficient collection of large tissue samples. Care is taken to cross the glenohumeral joint without damaging the cartilage by either rotating the device or closing the jaws.

As has been well established, we always place 3 anchors below the 3 o'clock position. Additional passes more superiorly are thrown as needed, as seen here by the 4th suture.

With sutures passed, the tissue can be advanced sequentially into knotless anchors.

We place the drill guide through the anterior inferior cannula for our first anchor on the face of the glenoid at the 6 o'clock position.

Once the anchor is engaged in the drill hole, the suture is tensioned, which advances the tissue onto the face of the glenoid. This is repeated for each subsequent anchor, creating a wall of capsular-labral tissue.

These biocomposite anchors provide interference fixation into the bone, with the addition of an internal locking mechanism to further secure the suture within the anchor.

Here we see the completed Bankart repair through the posterior portal and now from the anterior superior portal.

We now begin the interval closure by removing the anterior cannulas. ⁷ Through the anterior superior portal, a straight suture passer pierces capsular tissue inferior to the anterior inferior portal and then through the superior edge of the subscapularis tendon.

Again, through the anterior superior portal, a bird beak grasper is used to pierce the capsule just superior to the prior rent from the anterior superior cannula. Avoiding the biceps tendon, the polydioxanone suture is retrieved, and a nonabsorbable No. 2 braided suture is passed.

With both limbs through the anterior superior portal, this can be tensioned under direct visualization.

A second suture is then passed just medial to the exact location in the same fashion. In an attempt to avoid loss of adducted external rotation, care should be taken to prevent excessive inferior or medial suture passage into the subscapularis tendon. Furthermore, the interval sutures should be tied with the humerus in external rotation.

Anterior interval closure is employed in select patients where additional capsular plication is deemed necessary. Examples include contact athletes, those with hyperlaxity, patients with an inferior sulcus that persists in external rotation, and those undergoing revision surgery.

Although the clinical data supporting rotator interval closure are inconclusive, there is ample biomechanical rationale that closure of the rotator interval capsule decreases both anterior and posterior translation of the glenohumeral joint.^2,5,10

Results

Postoperatively, patients are placed into a sling for 4 weeks. Therapy is broken into 3 phases: passive, active, and resistive. Weeks 1 through 3 utilize guided, passive motion. Weeks 4 and 5 add active motion exercises through full elevation and internal rotation with 45° external rotation limitations. Week 6 begins a rotator cuff and periscapular resistance program, progressing the external rotation range of motion over 9 weeks.

Return to sport and activity has multiple variables and patient factors. In general, patients may resume a limited range of motion activities, such as chipping and putting, at 8 weeks and underhand swings, such as tennis ground strokes, at 12 weeks. We wait at least 5 months before returning to contact sports.

Discussion/Conclusion

We recently collected our outcomes data for 38 shoulders in an active patient cohort with a mean age of 27 years. With at least a 2-year follow-up and a mean of almost 4 years, outcome scores improved across the board, and the rate of recurrent instability was 10.5%. Two shoulders underwent revision surgery to address their recurrent instability.

Overall, our technique for Bankart repair and interval closure produced excellent clinical outcomes with low recurrent instability rates.