Arthroscopic Repair of Posterior Labral Tear with Paralabral Cyst Decompression

Anesthesia

1. Interscalene regional nerve block given in the preoperative holding area
2. General Anesthesia given in the Operating Room

Positioning

3. Place the patient in the lateral decubitus position
4. Ensure that all bony prominences are padded
5. The shoulder is then placed in 40 Degrees of abduction, 20 degrees of forward flexion, and 10-15 pounds of balanced traction
6. The shoulder is prepped and draped in the usual sterile fashion

Portal Placement and Diagnostic Arthroscopy

7. 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.
8. A posterior portal is established 1 cm distal and 1 cm lateral to the standard posterior portal that is used for routine shoulder arthroscopy.
   1. This portal is often in line with the lateral border of the acromion.
   2. Placement of this portal more laterally than typical allows adequate access to the posterior glenoid rim for later anchor placement.
9. An anterior portal is established high in the rotator interval via an inside-out technique with a switching stick.
   1. As an alternative, this portal can be established with a spinal needle via an outside-in technique.
10. The anterior switching stick is then replaced with an 7-mm distally threaded clear cannula.
11. Through the posterior portal, a diagnostic arthroscopy is performed.
12. The articular surfaces of the glenohumeral joint are inspected for chondral damage.
    1. The posterolateral aspect of the humeral head is inspected for any Hill-Sachs lesions (which may indicate combined anterior instability).
    2. 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.
       1. Concomitant SLAP tears are common with posterior instability.
    3. The rotator cuff is inspected (including the subscapularis tendon).
13. A switching stick is then placed in the posterior portal and replaced with an additional 7-mm distally threaded clear cannula.
14. The arthroscope is then replaced into the anterior cannula for viewing; it remains there for the rest of the operation.
    1. The posterior capsule and labrum are inspected and probed
    2. The anterior humeral head surface is inspected for any reverse Hill-Sachs lesions, which may indicate macroinstability.
       1. Typically the posterior labrum is detached and the capsule attenuated, requiring the placement of suture anchors.

Prepare and Mobilize Labrum

15. An arthroscopic rasp or chisel is used to mobilize the labrum from the glenoid rim.
16. The rasp is then used to debride the capsule to create an optimal environment for healing.
    1. A motorized shaver or burr can be used on the glenoid rim to achieve a bleeding surface for healing.

Place Anchors and Repair Labrum

17. An arthroscopic rasp or chisel is used to mobilize the labrum from the glenoid rim.
18. The rasp is then used to debride the capsule to create an optimal environment for healing.
    1. A motorized shaver or burr can be used on the glenoid rim to achieve a bleeding surface for healing.
19. Suture anchors are placed along the articular margin, not the glenoid neck, for the repair and capsular placation.
    1. Typically we use three, 2.3-mm 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
    2. The anchor pilot holes are predrilled and the anchor is inserted with a mallet.
    3. 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.
    4. The anchors are evenly spaced on the posterior glenoid rim for a symmetric repair.
20. 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.
21. 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.
    1. An inferior-to-superior direction is used for this maneuver to achieve a small capsular plication.
    2. This direction of suture passage is aimed at restoring tension to the posterior band of the inferior glenohumeral ligament.
    3. Patients with significant instability clinically may require a more aggressive plication than those with isolated pathology to the glenoid labrum
22. The PDS is fed into the glenohumeral joint and the passer is withdrawn.
23. 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.
    1. Grabbing the more posterior suture helps to ensure that the suture limbs do not become entangled.
24. The PDS is then fashioned into a single loop and tied over the braided Ultrabraid suture.
25. The opposite limb of the PDS is then pulled and the Ultrabraid is delivered through the labrum and capsule.
26. Additional sutures are then shuttled in similar fashion to complete the repair.
27. After each suture has been shuttled through the capsule and labral complex, it is tied using arthroscopic knot tying techniques.
    1. 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.
28. 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.
29. 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.
30. 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.
31. 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.
    1. Varying the distance of the suture from the portal incision allows additional tension to be applied to the posterior capsule.
32. 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.
33. The skin portals are closed with interrupted nylon suture and the patient is placed in a sling that allows slight abduction.

Inspect Results

34. Inspect the integrity of the repair.
35. 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.
36. The skin portals are closed with interrupted nylon suture and the patient is placed in a sling that allows slight abduction.