Basic to Advanced
William B. Stetson, MD
1. Cannulas
Smooth
Ribbed
Lipped
Partial Threaded
Fully Threaded
Flexible
5.75 mm, 6 mm, 7 mm & 8.25 mm x 7cm or 9 cm
2. Access
You need a reliable way to insert cannulas at a proper working angle
Use of a spinal needle for accurate placement
Confirm cannula angle prior to insertion
anchor placement
suture passage
Cannulas can also be used for storage and tying needs
Use of a switching stick to maintain the portal
3. Flexible Cannulas
Allow passage of larger instruments without the need for a large cannula
Easily conform to curved instruments
5.75 mm x 7 cm clear cannula
7 mm x 7 cm flexible twist-in cannula
4. Anatomic Landmarks
Supraclavicular fossa
Acromion
Clavicle
Coracoid process
AC joint
Lateral orientation line
where the posterior aspect of AC joint intersects the supraclavicular fossa.
used for establishing a lateral portal for a subacromial decompression,
arthroscopic rotator cuff repair, or conversion to a mini-open repair.
5. Use of Portals
It is still considered arthroscopic surgery as long as you dont connect the
portals Jim Esch, MD, speaking at an OLC course many years ago.
General Needs:
Viewing portal/s
Working portal/s
Anchor placement/suture portals
Isolate suture to be tied or passed in working portals
Anchor placement/Suture portals may not need a cannula
6. Anatomic Considerations
Anterior:
Stay lateral to coracoid to avoid neurovascular bundle
Axillary artery
Brachial plexus (Musculocutaneous nerve)
Inferior:
7.
Portal Placement
Workhorse Portals:
Posterior Portal
- viewing portal at the inferior edge of infraspinatus/interval between
infraspinatus and teres minor
The arthroscope is in the posterior portal, the lateral portal is in line with the previous drawn lateral
orientation line, and the anterior superior portal is near the AC joint.
Accessory Portals
midglenoid portal - Bankart repair
anteroinferior portal (5:00)- low anchor placement
Neviaser portal - RTC repair
port of Wilmington posterior SLAP
posteroinferior portal (7:00) - posterior Bankart
Posterior
8. Portals for SLAP Repair
Standard Posterior Portal
Anterior
viewing portal
Anterior Superior Portal
Anterior Midglenoid Portal
made at the leading edge of the subscapularis
Arthroscope is in the posterior portal, with twin anterior working portals, the anterior superior portal (left)
and the anterior midglenoid portal (right).
Port of Wilmington
posterior SLAP tears
one cm lateral and one cm anterior to posterior lateral corner of acromion
percutaneous spinal needle technique to find trajectory (as in all
percutaneous access)
thru cuff muscle for posterior SLAP anchor placement
no cannula is necessary!
The port of Wilmington is made one cm lateral and one cm anterior from the posterior lateral corner of the
acromion.
viewing portal
Anterior Midglenoid Portal
working portal for anchor placement
Figure 1
Figure 2
Figure 1 - The arthroscope is in the anterior superior portal viewing inferiorly which enables one to see the
anterior neck of the glenoid and the anterior labrum (left shoulder).
Figure 2 By viewing from the anterior portal, this allows for proper placement of anchors at the edge of
the articular surface (right shoulder).
viewing portal
working portal
The arthroscopic cannula is inserted into the posterior portal, underneath the acromion. A switching stick
is then placed through the cannula and out the anterior superior portal. A second cannula is then placed
anteriorly and the assistant hold both cannulas end to end.
The arthroscope is then placed posteriorly and the arthroscopic shaver is placed anteriorly, at the tip of the
arthroscope. Careful debridement is then performed of the bursa to create a room with a view.
Anterior
Posterior
Some complex tears are best viewed from the lateral portal with the working cannulas placed both posterior
(left) and anterior (right).
Anchor placement can be made percutaneously through the portal of Wilmington or anywhere off the
lateral edge of the acromion depending on where anchor needs to be placed which is determined by the
direction of the spinal needle.
The modified Neviaser portal is located in the supraspinatus fossa slightly more medial to avoid injury to
the suprascapular nerve and for easier passage of instruments through the rotator cuff from medial to
lateral.
Suture Management
A. Good suture management is a critical skill in arthroscopy shoulder surgery. To
minimize suture breakage which occurs from fraying of sutures against sharp
instruments or edges of canullas. If sutures are entangled then repeated manipulation
of the sutures to unentangle them leads to suture abrasion and breakage. Sutures
placed properly are more likely to slide well and result in more knot and loop
security. Vast amounts of time can be saved when these techniques are mastered. This
time results in decreased soft tissue swelling and better results.
B. Basic Concepts:
1. Triangulation
2. Suture marker
3. Portal issues
4. Suture or anchor first techniques
5. Concept of inner and outer limbs
C. Triangulation technique essential for cannula placement, suture marker and suture
retrieval. A technique that will save time and is beneficial in large people is the
following:
1. Visualize desired entry site with scope
2. Externally visualize from needle entry site
3. While looking at shoulder direct toward forward tip of scope
4. Confirm on scope monitor
E. Correlation of findings
Bursa
Joint
F. Suture management
1. Frequently facilitated by 3rd portal
a. 1 Scope, 2 instruments, 3 retrieval devices
2. Tie knots from portal from which anchors placed (unless anchor was inserted
percutaneously)
3. Never place knot down canulla with more than 1 suture set
G. Creating portals
1. Inside out
2. Outside in
1.
2.
3.
4.
Anchor on Corner
Tie a knot
M. Knotless Anchor
Knotless anchors are well suited for the lateral row in dual row rotator cuff repairs.
They tend to roll the edges of the cuff down so that the cuff edges dont get caught on
the lateral edge of the acromion and there are no lateral knots to get caught either.
When tying knots for Bankart repair, it is possible to engage the labral tissue and roll
it up onto the glenoid rim creating a soft tissue buttress. This is much more difficult
with the knotless design. The length of the loop in the anchor is fixed and therefore a
proper bite of tissue must be taken so that the proper tension will be applied to the
suture when the anchor is seated to the proper depth. Too big a bite will result in
difficulty in inserting the anchor subcortically without cutting through the tissue and
too small of a bite will result in a loose repair.
N. Dual or Triple Suture Anchor
1. Screw in
2. Rotator cuff
3. Different colors
4. Stress distributed over broader area
5. Necessitate a third cannula to park one or both sets of sutures (Neviaser portal)
O. Super Sutures
One of the long standing challenges of arthroscopic stabilization and rotator cuff
repair procedures has been suture breakage. The newest generation of sutures has
greatly reduced this problem. Each company has its variation in this area. All tend to
be much stiffer than Ethilbond or braided polyester and suture ends are more proud.
All require specialized suture cutters to cut the knots. Make sure that you have the
proper cutters before you use these sutures.
P. Blind Knot Cutter
1. Guillotine design
2. Prevents knot cut out
3. Works well when visualization poor
4. Rotator interval closure
Q. Suture Shuttle
Braided suture is too flexible to feed it through a suture hook device and therefore some sort of suture
shuttle is passed through the suture hook first and used to retrieve the braided suture through the tissue.
This can be a commercial suture shuttle (Linvatec) or there are various substitutes. Doubled over #2-0
prolene is an easy substitute but attention must be paid to the direction that the suture is passed. An
easier way is to pass a #1 PDS suture through the tissue first and then tie the appropriate end around
the braided suture with a simple knot. Various companies make devices such as the Arthrex bannana
device which has a doubled nitinol wire in it.
1. Doubled over #2-0 prolene
2. Simple #1 PDS
3. Disposable versions
2. Shoulder Suspension
A. Suspend arm with 10lbs of weight.
B. Approximately 70 degrees of abduction.
C. Approximately 15 degrees of forward
flexion (Figure 1).
B. For a simple stitch, now tie the suture either using a sliding knot and a series of
half-hitches.
10. Suture Passage Second Limb of Suture for Mattress Stitch
A. For a mattress stitch, grasp the other limb of the suture from the anterior superior
portal through the mid-glenoid or superior portal with a crochet hook. (Figure 8)
B. Using the crescent hook or angled penetrating retriever from the anterior superior
portal, pierce the labrum about one cm from the previous suture limb. (Figure 9)
C. Retrieve the suture back through the labrum and out the superior portal. Now tie
with a Revo knot, you cannot use a sliding knot with a mattress stitch as the
suture does not slide well. (Figure 10)
Figure 10 A mattress stitch is created and tied through the anterior superior portal.
established percutaneously using the small insertion cannula for the specific
anchor being employed. Use needle locaization to establish the portal at the
appropriate position aiming toward the posterior-superior glenoid rim(figure 11).
B. Drill/tap and insert the anchor as described for the anterior anchor.
C. Retrograde the suture through the labrum using an angled hook or penetrating
retriever inserted through the anterior-superior portal. The suture can also be
retrograded through the labrum using a percutaneous posterior-lateral
portal(figure 12).
Qu ick Tim e a n d a
Ph oto - JPEG de com p res s or
a re n e ed e d to s ee thi s pi c ture.
figure 11
figure 12
D. Deliver both suture limbs into the anterior-superior portal and tie. Use a sliding
knot if the sutures glide well, a Revo knot if they do not.
13. Evaluating the Repair
A. After tying the knot, cut the sutures and evaluate the repair.
B. Place a probe through the anterior superior portal and probe the superior labrum
to make sure the repair is adequate. (Figure 13)
Figure 13
6. Replace the scope in the posterior portal and develop the anterior inferior portal.
Needle is placed lateral to the coracoid, entering above the subscapularis tendon
adjacent to the humeral head. An 8mm cannula can be placed(figures 1 and 2).
7. Capsular labrum mobilization. This is a very important step, otherwise the capsule
cannot be tensioned appropriately. Elevator instrument placed between the labrum
and the glenoid to elevate the soft tissues off of the glenoid neck anteriorly and
inferiorly. An RF probe can also be used here effectively with less bleeding. (Figure
4)
8. Prepare glenoid neck. Shaver blade followed by gentle burr to debride devitalized
tissue.
(Figure 3)
Figure 3: Left shoulder viewed from anterior portal. Shaver blade followed by gentle burring
the glenoid neck or tissue reattachment.
to
9. Test mobility of capsular ligaments with a suture hook. If the capsule cannot be
advanced superiorly by at least 1.5cm, consider a capsular split-shift. This will also
tension the inferior and posterior capsule (figures 4,5,6).
10. Without a split-shift, if an inferior pouch is identified, consider plication stitch in the
mid substance of the inferior glenohumeral ligament. (Figure 7)
11. Drill holes for suture anchors along glenoid using a drill guide through the inferior
cannula. Position a drill bit onto the anterior inferior surface of the glenoid,
approximately 2mm into the joint from the articular edge. Create drill hole followed
by second and third drill holes with 1cm spacing. (Figure 8)
Figure 8: Right shoulder viewing from anterior superior. Suture anchor drill holes on the articular
cartilage margin.
15. Shuttle a braided suture from the superior cannula under the labrum and through the
capsular ligament exiting out the inferior cannula. This can also be performed with
the scope anteriorly superiorly and utilizing the posterior cannula for shuttling
sutures. (Figure 7)
22. Place the scope anteriorly and further visualize the Hill-Sachs lesion posterior to the
glenoid with the arm out of traction and attempt rotation to visualize the concentric
reduction of the humeral head.
23. Rotator interval closure in selected cases. The tightness of the closure depends on
how superior you pass the suture through the interval capsule and the number of
sutures placed. With the scope posteriorly, use a right suture hook on a right shoulder
to grasp the superior border of the middle glenohumeral ligament. The hook can be
passed through the superior capsular ligament posterior to the biceps. Introduce a
suture and tie. A reverse suture hook can then be introduced through the large
cannula behind the biceps, grasping full-thickness superior glenohumeral ligament
and followed by middle capsule ligament. The sutures can be placed sequentially
from the glenoid edge to the lateral-placed cannula. (Figure 10)
Figure 10: Left shoulder. Suture hook introducing grasping middle glenohumeral
ligament and superior glenohumeral ligament behind the biceps closure of the interval
as knots are tied.
24. Additional plication sutures can be used to balance the repair and center the humeral
head as needed. Options include the posterior band of the inferior glenohumeral
ligament, inferior or anterior capsular pouches.
Plication sutures are placed with the suture hook approximately 1.5cm from the
glenoid labrum, a full-thickness capsular bite is made. The hook is drawn superiorly,
and a second pass of the hook is placed under and through the labrum. A
monofilament suture is passed as the suture is tied, creating a pleating effect of the
ligament against the glenoid. The option for a shuttle followed by a braided suture in
cases where a permanent stitch is preferred. This is best utilized when the labrum is
intact to the glenoid and therefore serves as a suture anchor. (Figure 11)