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DVD-1106_002 | A | Arthroscopic Bankart Utilizing the PushLock® Anchor

Kyle Anderson

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Arthroscopic Bankart Utilizing the PushLock®  Anchor

In this procedure, we're going to perform an arthroscopic bankart procedure using PushLock anchors. The patient had an unusual presentation, having had some instability and then a loss of motion. We hypothesized that he had an ellipse, lesion or some healing to the neck of the glenoid. So it's anticipated that we'll need to loosen that labrum and then advance it up onto the edge. So this patient has evidence of anterior instability both on his exam and on MRI. Interesting. Development in him is he actually lost motion for a for a while. I suspect he probably has tried to heal his labrum and capsule to the medial neck or an Alps lesion, so he had a lot of difficulty getting his motion back. Now he's got reasonable motion, but you can see he still has symptoms of instability. We'll do a load and shift just with a little bit of axial pressure into the glenoid. And with the shift you can somewhat appreciate the back corner of the acromion, which is right here. And he comes just about all the way. He's a certainly a grade two. He doesn't quite stay all the way out, so he's probably a two plus. But there he's coming out anteriorly. Posteriorly is reasonably stable. The procedure begins with a post standard posterior portal and the glenohumeral joint is inspected. We're going to start a more inferior anterior portal for placement of our anchors. This is the primary portal and the one I would use in a single portal technique. We may go to a two portal technique here to just demonstrate an easier use of the lasso. And just going to introduce a small cannula here initially. So anterior cannula here just above the SpeedScap you see there. He's got a little bit of fraying of his scalp right there that will breed kind of a diminutive middle glenohumeral ligament right here. Pretty good anterior band of his inferior glenohumeral ligament here. But you can see where he's detached that and he's coming down here. This is probably about the 530 position on this right shoulder detachment here. And then it is reasonable up here just in front of the biceps. So not truly any kind of slap tear there. But one thing that I like to pay particular attention to in a instability case such as this, is looking at the posterior aspect of the labrum, and we'll get into that from another view in a minute. The other thing that you can do on an at the time of arthroscopy, if you get his arm up in the right position, hold the scope there. We can just do our load and shift. Test under direct visualization. And you can literally watch the shoulder come right out of the socket here. He's got a little bit of a Hill-Sachs kind of scuffing there. Not really a true defect. Mobilize this labrum just a little bit before we start to repair it. So we're going to basically complete the detachment that he had. This will allow us to prepare the glenoid neck. There is some scarring of the labrum to the medial neck. And so this labrum does require mobilization before it can be sufficiently advanced up onto the edge. So mobilization of a particularly an Alps or medially healed labrum is very important. We're going to introduce an eight millimeter cannula. Now that will allow us to pass the SutureLasso. And basically anyone that we want. Now a second cannula can be placed higher through the through the rotator interval. And this is a five millimeter cannula for passage of suture. Okay. So now if you can see this we're going to use a 45 degree lasso that's got a passing wire in it. And then we're going to take this out the top here. We're going to determine how much capsule we'd like to grasp along with our labrum. And then determine how far superiorly it has to be advanced. We're going to wind this through and just come at the lower portion of the labrum here. Now let me see the KingFisher. So we'll go ahead and grab this. This is this is going to be a cinch stitch that we're doing. So we're going to place the loop on the outside of the labrum. So that's going to be the first one to come through. Here is the is the loop. And I'll keep my hands on the tails there. Okay. Clamp a KingFisher is then brought through the anterior-superior cannula to to retrieve the suture. All right. So now we've got both ends out and we'll wait. And we're just clamp these for a minute until we drew. I'm going to drill first before we make our little cinch. A drill hole is placed again about 5 or 6mm above the suture. It is very important to place this pilot hole on the face of the glenoid, and not on the edge or on the neck of the glenoid, as this will not allow for a proper restoration of the bumper effect. Now, we're simply going to pass these sutures through here, through the loop. Generally a good idea to make sure that these are not wrapped on one another. So I'm just going to come back through and grab them again. That way you know for sure that they're not wrapped and just simply pull this through. The FiberWire is then brought through in a doubled configuration such that such that the loop is on the outside of the labrum. Okay, so that puts that in position. Now we simply just pass our PushLock in the relatively standard manner. Here's the PushLock. We're going to feed that through here. I like to work on my tension as I'm pushing it down. So I will just take a general guess as to my what I think is going to be the appropriate tension. And now go ahead and advance it, just because I've gotten a feel for the distance that this peak eyelet has to be advanced. One key element here is that Stacy's pulling up on the humeral head and back a little bit. That allows me to advance that capsule and get this bumper up where I want it. And we're going to bury that down past the laser line, unscrew it six times, and then cut off our excess suture. You can feed the feed the suture through this cutter, but I find it easier just to come down and cut it off. Here's that bumper effect that we're looking for. A lot of people are concerned about not being able to place a knot back here. My view is, as long as you place the pilot hole onto the face, you can still reestablish that bumper effect. And then we don't have to worry about a knot gradually migrating its way over to this surface. Here, even highly skilled surgeons who place their knot on the outside of the labrum over time. I've seen at revision cases a well positioned original knot gradually toggle its way over back to the articular surface. So that's one major advantage of this. Okay, so here we're going to just take a 45 degree lasso with our passing wire. And so you can see some of the anterior band I want to get just slightly above that into some of this capsule here. And again, we're going to walk up the neck until we have that suture coming out right at the interface of the labrum and the glenoid. With this second anchor, a FiberLink is used. And this greatly simplifies placing a cinch type of suture. A FiberLink is then shuttled into position, bringing the tail back out through the anteroinferior cannula. Now come back and bring both of my sutures out the same anterior cannula. This tail is then simply passed through the loop end of the FiberLink, and when pulling on the tail, the loop is advanced down toward the labrum and capsule. Again, I'm on to that face by a millimeter or more. So here's our PushLock. Here's the tail. And very easy to to pass this. Will sink that in once the appropriate tension has been applied to the tissue. The anchor itself is advanced by tapping on the plunger and it forms a nice cinch suture, but again is easier than with the traditional FiberWire. The introducer is then removed. The excess suture is removed by using the open ended FiberWire cutter. So, so far two anchors and anchors in place. There will go one more here. Rather than going with a passing suture through through the SutureLasso, we're just going to go directly with a FiberStick through. So it saves us a step here. We're going to leave a little bit of it exposed in case we have trouble advancing the suture. We at least have that much exposed so we can grab it with our KingFisher I definitely don't want to advance this over. That's middle glenohumeral ligament. You can over constrain them. But I do want to grab some of the labrum in back here. And again we're just going to try to advance that right through the labral glenoid junction here. Again with the tip exiting the labrum just between the labrum and glenoid. And now just pull that back out. Go retrieve our suture. And it's very simple. Drill hole is placed this time. The drill does not need to be as high relative to the suture. It can be essentially 1 or 2mm above depending on how much tissue needs to be advanced. But generally the higher on the glenoid, the less superior tension needs to be applied to the capsule. These are then loaded on the PushLock. The anchor is brought down through the cannula and then the appropriate tension applied to the tissue. Generally speaking, it's pretty easy to over tighten this small labrum here. So I want to leave a little bit of slack. And if you want to leave a little bit of slack in the suture, you can just simply rotate it before you advance it. And once the appropriate tension is applied in the laser line, the initial laser line is buried. Then the anchor can be advanced by tapping on the plunger. Okay. So. Now we're going to bury that laser line. I think it's really important not to be advancing too much capsule when you're above the equator of the glenoid, because that tends to be more of a constraining measure than a stability measure. So you notice that there's not really any significant capsule being pulled up by that. It's just simply putting the labrum back on. Whereas these two down below, we're really looking to advance that capsule up quite a bit. In the past we would be done at this point, but we're paying a lot more attention to this back posterior aspect of the inferior hammock. You see all that stripping of the labrum back there that concerns me. So instead, rather than just calling it quits with the anterior, we're going to go ahead and put one little stitch back there as well. And again I'm going to be medial to the. As I place a posterior portal here I want to be medial to the muscle tendon junction. So I want to be right in here. Now again this is a patient who's never dislocated his shoulder posteriorly. He's dislocated it anteriorly. But yet you look at the back part of the inferior glenohumeral ligament and the posterior inferior labrum. And you see this. So I think this is why a lot of these failed. Because with gradual external rotation of the shoulder, this indirect inferior capsule is still incompetent. The idea here is to stabilize the stabilize the other half of the inferior hammock. It's really not designed for posterior instability. It's for anteroinferior or direct inferior instability. Gotcha. Keep going. Good. Now, just a kind of a percutaneous method here. We'll pass the suture down through the posterior band and then up through. So I'm going to pass it in here. I'm really not trying to come through my original portal at all. Okay. This is a, a micro SutureLasso that we've preloaded a FiberStick. We've got a little bit of the FiberStick or FiberWire exposed so that if it won't advance, then we'll have be able to at least grab that portion of it. So we're just going to come in, come down below, get some of that posterior band up, and then come out at the junction of the labrum and chondral surface. Okay. So now we're going to take the KingFisher and find the other one here. So here we are. We've got that suture. Now they're both coming out the same cannula. And one last PushLock. Now we're going to advance our last PushLock in. And we're going to bury that laser line again. Synch stitches one down below there and one right here. And you see again, know not to cause any trouble with our articular surface. If you had true posterior instability, we'd be marching up further along here. But he really doesn't. Now, we've brought up some of that back half of the capsule. You can see how we've evened it up with the tightness in the front. By advancing that up, there's really no room for him to escape down below or straight inferior. All right.

Arthroscopic Bankart Utilizing the PushLock® Anchor

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