Name: Double Row Labral Repair: Technique & Indications
Uploaded: 2012-09-27T00:00:00Z
Channel: Arthrex

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VPT1-0009-EN | A | Double Row Labral Repair: Technique & Indications

Chris Ahmad

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Double Row Labral Repair: Technique & Indications

But let me show you a little bit of philosophy about this double row label repair. These are slides that I used early on in early 2000 on how to have the most ideal arthroscopic labor repair. You can see the position of the anchor and where the labrum should be reattached. And here's my own case trying to demonstrate ideal preparation. The anterior glenoid is abraded. You have exposed bone and you get the anchor right on the glenoid face. So you're going to recreate a so-called bumper. But the concern that started to grow was we're putting anchors on the glenoid face. There's cartilage. Bone does not like the soft tissue is not going to want to heal the cartilage as well as it wants to heal to the bone that you just spent time preparing. So to take advantage of that bone, we decided to look into the double row repair. So on the glenoid face, it's not anatomic in the capacity, as we said, may not be as good as we want as the anterior glenoid neck. So let's take it to the laboratory and let's really look at what the footprint is. Since it was not really clear to us what it was in normal cadavers. And so here we've dissected off the capsule label complex, and we had a number of cadavers, and we looked at the footprint. Mediolateral footprint of the capsule label complex is about a centimeter. It's not that much smaller than the supraspinatus, which we've done extensive amounts of research and have such a strong argument for the supraspinatus to have a double row repair. And this is a technique that we first tried in the lab. Medial row of anchors. These are suture tax plates that goes through the capsule label complex. And then back on the glenoid face with a push in anchor a PushLock. So this has now has the advantage of having a knotless type of system. We know the features of knots. Neal Elattrache spoke to us about how it can affect the rotator cuff. It also is very damaging to the humeral head if it makes contact with the humeral head. So this is what it looks like in the laboratory. If we measure that actual footprint when you have that single row repair right on the face. You get maybe 40% of that anatomic footprint restored. If you do this double row repair, you get up to 90%. Probably you could get even more if you were a little bit better with the technique. And we're strong on the learning curve. This is a case just from last week. I haven't even seen this patient in follow up yet, but I did want to share with you this is a typical case that that I would see and do and perform. So it's real. And I also want to illustrate it's not a big deviation from what we're actually doing. So he's 20. He's an outfielder. Since his last season he had a problem with his shoulder diving for a catch. And he had a spontaneous reduction. He's got a bunch of subluxation events. So during his diagnostic scope this is just to illustrate. This is a bad shoulder. He's got a type four slap. And we're going to address his his slap lesion. And then he's got a little bit of wear in the lateral position here. He's got some level of mild glenoid deficiency. And we've done some preparation there. You see on the right where we have all of this glenoid neck. So rather than just fix up here, we're going to take some advantage of that glenoid neck preparation. It's not really the purpose to go over this slap repair, but it is interesting. It's a type four slap and we did elect to fix it in this case. But I'm going to move on. Just to go over to more of the illustration of how we go forward with a double row repair. So this is viewing from anterior. That's about 6:00. And that's a percutaneous approach from posterior. I like putting posterior inferior anchors. And this happens to be torn labrum as you see here. But even if it's not torn we'll do some slight level of imbrication in this area because I really feel it eliminates the need to do this so-called capsular shifting going from inferior to superior. And when you come from posterior, it's so easy to get access to 6:00 position. You can move the humeral head anterior. It's unstable so you can get out of the way. Everybody's familiar with these techniques, so we're putting in an anchor. It's percutaneous. And then we're going to use our posterior working cannula for suture management. And I really like doing percutaneous techniques. So instead of putting a second posterior cannula this is a lasso. It comes in percutaneous very easy to find the same hole percutaneously. There's so much flexibility. You can really go to your ideal placement. You're not inhibited by the cannula. The cannula is not falling out. And so you can get nice a nice ability to get your desired level of tissue. So typical suture passing. And so this is not a double row here. Of course this is just standard simple. Suture passing techniques. And then we're going to continue that up. And we're going to take care of all of this posterior labrum. So this is extensive labral tear. If it's not 360 it's 355. And then we'll Another thing I like to do is you work posteriorly up. It's very nice. We're still looking anteriorly. This is a posterior labrum. You can come through the Wilmington portal. So typically for the posterior aspect of a Slap lesion is extension of the slap lesion. So this is coming through the Wilmington portal. And we'll bring in our guide Percutaneously. And so just another way to get access to the posterior labrum as it goes more superiorly. And you see we're not tying. We're leaving all of these sutures past and not tying. If you tie right away you tend to tighten the shoulder. And then when you go anterior, it's going to be a little tighter and harder to work with. Okay. Now we're going to get to the anterior labrum. And I did prepare the anterior labrum initially from the get go. It's nice to keep the seal together. So we wait until we're going to actually work on that tissue. So we don't have bleeding. We don't have soft tissue extravasation. And of course we spend a lot of time with preparation for healing. Now part of the of the philosophy of doing this double row repair is we want to take advantage of this footprint. We want to really maximize our fixation and creating a biologic environment for healing. So we're going to abrade it. And then our mechanical construct is going to favor biologic healing with compression of the tissue. Now the reason why I say this is similar to Peter. This is extremely common. The more I look at it, the more I see it. This labrum we're going to keep on mobilizing. But you'll see in that labral tissue there is a sliver of bone. So it's very common. You won't even see it on x ray. You may appreciate it on MRI, but it's a sliver of bone that hangs out right on that labral tissue. It makes the tissue very robust. This is a percutaneous technique with a kit that Arthrex makes. It's a spinal needle type that goes in. And then you put a wire over the spinal needle. So this is going to come in at a very low position on the glenoid. There's no cannula. We're working percutaneously. So over that wire you put in a dilator and then over that dilator we're going to put in the drill guide. So now So now we're. You can see where we were posteriorly. This was around 6:00. So we're about 3 or 4mm away so we can get really low. We're going to imbricate tissue rather than just merely shifting with this concept of shifting. And then this is everything is normal instability repair. So far we haven't gotten to the double row technique. But here's percutaneous and we'll get our most inferior tissue. This is probably the most critical anchor in suture passing of the whole procedure. Now we're going to move to the. The double row aspect. We've changed to the anterior portal. We're bringing in the guide. We're going to put this medial on the glenoid neck. We're drilling. And then we're placing a SutureTak strong bone. Excellent fixation. And now we're going to grab both sutures. Both sutures are going to pass. The more inferior anchor hasn't been tied yet. If you tie that anchor, you limit the mobility of this tissue. And you really want to be able to lift this tissue up, especially if there's bone inside. If there's bone inside, you may not be able to pass around the bone. This has a sliver of bone. And so you really want to get as deep and down on that tissue pass. So if the tissue is mobile makes it easier. If you tie that anchor, that inferior anchor the mobility is decreased. Makes that really tough. And so we retrieve the suture. And now we're going to shuttle. And we have two sutures that are through that most medial anchor. And now this is another above the area that we're going to do the do the double row technique. We're putting in another suture. It's on the glenoid face. So this is standard typical anchor placement, suture passing. But we haven't tied anything yet. Now we're ready to go and we'll tie the first anchor. It's inferior. Nothing special about this. So I'll just go over to the next step. So we've tied the inferior anchor and there's some skepticism or some arguments that maybe if we use this technique we're going to create an illusion. We're going to overutilize the tissue. But as you can see, at least if you put above and below some simple sutures, it's not medicalizing. In fact, we got the cannula and we're going to pull this on to the glenoid in a way that I don't feel like we're creating an iatrogenic Alps. And so here's a PushLock coming in. So this is going through the cannula. This is the drill guide for the PushLock. This will go on the glenoid face. 2.9mm PushLock with the appropriate drill guide. Now we set the tension. And then we have our PushLock in place. And so we have fixation and compression against that healing area. And this is one of the nicest features is its knotless. There's no knots. There's no abrasion characteristics of this. So we have the anterior side fixed. And then we're going to that's what it looks like from the superior portal. And now we'll go over and simply tie the posterior label tissue. And then we're going to do the slap repair also. So this is what it looks like. So who do we do this operation on. What's important I think the indications are important. And the anchor placement, the sequence I find if if you do it in different sequences, of course you can get through it. But it's useful to keep the sutures free without knot tying, to keep the shoulder a little loose until you get through all your suture passing. So for me, there's this subset of patients, because of the spectrum of instability that we see that are not quite ready for a bony operation because they don't have that much bone deficiency or they're not a collision athlete. It's that middle ground patient that is slightly higher risk. Maybe they have an alpaca, maybe it's a revision. Maybe it's a collision athlete without bone deficiency. Maybe it's mild bone deficiency. There's some arguments that young patients have a higher failure rate with standard instability operations. And for me, I really like it for this sliver of bony bankart that you probably see more often if you really look for it. And it exists more often than I've appreciated. Thanks very much.

Double Row Labral Repair: Technique & Indications

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