Placing Knotless Suture Anchor Through Mid-Glenoid Portal

1. Portal Placement

1. The mid-glenoid portal/anterior-inferior portal should be made approximately 1 cm lateral from the joint line of the humeral head and just superior to the subscapularis through the rotator interval. Portal placement is guided by the preliminary placement of an 18-guage spinal needle to ensure the trajectory of the portal is correct.

2. Portal placement avoids injury to the labrum and should be determined after assessing both the thickness of the local soft tissues and the size of the relevant bony architecture.

2. Glenoid Preparation

1. The drill hole for the knotless anchor should be drilled approximately 1–2 mm onto the face, or from the cliff, of the glenoid.
2. The drill can be malleted down lightly to hold the drill in place while drilling anchor holes.

3. Anchor and Labral Tape Preparation

1. The inferior-most anchor is placed first. Using the anterior portal, a drill hole is made on the lower part of the glenoid, about 2 mm onto the articular surface. This is usually at the 5:00 or 5:30 position. Ensuring this anchor is placed sufficiently low is crucial for effectively addressing the pathology and achieving a successful repair. A suture anchor is placed at a 45-degree angle to the glenoid face using a mallet. Through the anterior portal, a tissue penetrator with a monofilament wire loop is inserted through the capsule and under the torn labrum at the 5:00–5:30 position. The tissue is grasped more inferiorly than the anchor to achieve an inferior to superior and lateral to medial capsular shift. Be cautious of the axillary nerve near the 6:00 position.
2. After passing through the soft tissue, the wire loop is released, and the penetrator is withdrawn from the capsule and removed from the shoulder.²⁴
3. The labral tape is passed a short distance through the eyelet of the knotless fixation device   before the construct is inserted into the glenoid.

4. The flatter, non-cylindrical labral tape provides a flat construct that wraps around the labrum to reaffix it to the face of the glenoid.

4. Knotless Anchor Fixation

1. A hemostat can be used to hold the tape as it is placed into the drill hole, and a mallet is used to drive the interference portion of the plastic implant to a marked depth on the percutaneous insertion device denoted by a black line.
2. Once the suture anchor is securely affixed, the insertion device is unloaded and pulled out of the portal with 6 counterclockwise turns.
3. Tightening the anterior band of the IGHL is crucial for a successful Bankart repair. This is done by suturing the labrum at the 6-o’clock position to an anchor at the 5-o’clock position, creating a south-to-north capsulolabral shift, typically using a curved suture passer.²³