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Portal Placement for Shoulder Arthroscopy:

Basic to Advanced
William B. Stetson, MD
1. Cannulas

Partial Threaded
Fully Threaded
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
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
Stay lateral to coracoid to avoid neurovascular bundle

Axillary artery
Brachial plexus (Musculocutaneous nerve)

Stay up and away from the 6:00 position


Off posterior/lateral surface of humerus

At base of Scapular Spine:
Careful with Nevaiser portal into joint


Portal Placement

Workhorse Portals:
Posterior Portal
- viewing portal at the inferior edge of infraspinatus/interval between
infraspinatus and teres minor

Anterior Superior Portal

- working portal in the rotator interval near the AC joint
- inside out or outside in technique

- useful as a working portal for rotator cuff repairs and for

arthroscopic Mumford procedures
Lateral Portal
- subacromial working/viewing portal placed 2 cm lateral to the edge of
the acromion in line with the lateral orientation line
Hold the Arthrosocpe with Two Hands! Train your assistant to hold the
arthroscope with two hands. This steadies the picture for the surgeon and allows
the surgeon to use his two hands for precise anchor placement, suture
management and knot tying.

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

8. Portals for SLAP Repair
Standard Posterior Portal


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

9. Portals for Bankart Repair

Standard Posterior Portal
working portal
Anterior Superior Portal

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).

10. Accessory Portals for Bankart Repair

5:00 Low Anterior Portal

below subscapularis (Tibone)
7:00 Low Posterior Portal
through or inferior to teres minor
percutaneous or with small cannula
posterior Bankart
11. Portals for the Subacromial Space
Standard Posterior Portal
Anterior Superior Portal

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.

12. Portals for Rotator Cuff Repair

Standard Posterior Portal
viewing portal
Anterior Superior Portal
working portal near the AC joint
Lateral Portal
working portal and viewing portal
50 yard line

acromioplasty and rotator cuff repair repair

large cannula (8.25 x 7mm or 9 mm): large instruments


Some complex tears are best viewed from the lateral portal with the working cannulas placed both posterior
(left) and anterior (right).

13. Accessory Portals for Rotator Cuff Repair

Postero-lateral Viewing Portal
especially useful to visualize anterior cuff tears
Portal of Wilmington
percutaneous anchor placement
one cm lateral and one cm from the posterior corner of acromion
spinal needle technique to find trajectory
this can be modified and placed percutaneously anywhere along the lateral
edge of the acromion depending on where the anchor needs to be placed
no cannula necessary
suture Parking

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.

Modified Neviaser Portal

rotator cuff repair portal
passes thru trapezius from medial to lateral (notch)

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

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
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

D. Suture marker technique

1. Correlate joint and bursal path.
2. Useful for partial RCT
3. 18G Spinal needle
4. Monofilament suture
5. Place suture outside cannula

E. Correlation of findings



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
3. Never place knot down canulla with more than 1 suture set

G. Creating portals
1. Inside out
2. Outside in

H. Suture first fixation: Using as an example Type II SLAP repair

1. Deride labrum
2. Prepare bony bed
3. Drill hole
4. Pass suture thru labrum
5. Pass anchor
6. Tie knot
* With suture first technique, the anchor needs to be loaded on the "inside" suture
limb (not through tissue) so it can be slid down cannula into bone. In contrast, the
knot needs to slide down the "outside" suture limb to cinch down the tissue firmly
to the anchor in bone.

I. Debride bony bed

J. Drill Hole on Corner

K. Suture through Labrum and Insert Anchor

L. "Anchor First" Fixation: Using as an example a Type II SLAP


Prepare bony bed

Drill hole & insert anchor
Retrieve suture through tissue
Tie knots

Anchor on Corner

Grasp suture from the anchor

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

Arthroscopic Repair of a Type II SLAP Lesion

1. Patient Positioning
A. Lateral decubitus position.
1. Pad all bony prominences.
2. Axillary roll if necessary.
3. Tilt patient approximately 20 degrees posterior to orient glenoid parallel to
4. Keep head of patient clear of anesthesia so surgeon can access anterior
5. Hypotensive anesthesia if medically appropriate (Systolic BP<90).

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).

Figure 1 Patient positioning in the lateral decubitus position

3. Outline Anatomical Landmarks (Figure 2)

A. Supraclavicular fossa.
B. Acromion.
C. Clavicle.
D. Coracoid process.
E. Anterior Portal
F. Posterior Portal
G. Port of Willmington
Figure 2 Anatomical landmarks looking from
posterior to anterior.

1. Establish Posterior Portal

A. 1-2 cm inferior and 1-2 cm medial to posterolateral corner of the acromion.

B. Direct cannula toward the coracoid process anteriorly.

2. Establish Anterior Superior Portal
A. Outside in technique is preferred. Insert 18 gauge needle into joint under direct
visualization at correct entry point and angle.
B. The intra-articular entry point should be directly below the biceps tendon.
a. Incise skin. Follow with a blunt conical point switching stick.
b. Push cannula of choice over switching stick. Use dilators over switching
stick for larger screw in cannulas.
3. Complete Diagnostic Exam of the Glenohumeral Joint
A. View from the posterior portal.
B. View from the anterior superior portal.
C. Special attention to the superior labrum.
D. Assess other pathology including the rotator cuff, anterior and posterior labrum
and biceps tendon.

4. You may establish a mid-glenoid (mid-anterior)

portal if desired but this is only mandatory for
more extensive anterior labral repair
A. Outside in technique.
B. Spinal needle enters 1.5 cm lateral and 1.5 cm
inferior to tip of the coracoid process.
C. Enters the joint at the superior (leading) edge
of the subscapularis tendon.
D. Establish a secure cannula (e.g. 8.5 mm
threaded cannula)
(Figure 3)
Figure 3 Viewing from the posterior portal,
two anterior cannulas.

5. Creating a Type II SLAP Lesion

A. In the laboratory, with the scope in the
posterior portal, place a small liberator
elevator through the anterior superior portal.
B. Elevate the biceps attachment from the
superior rim of the glenoid.

6. Preparing the Insertion Site

A. With the scope remaining in the posterior
portal, place a small round burr (4.0 - 4.5 mm)
or shaver through the anterior superior portal.
B. Lightly burr the superior glenoid tubercle in

Figure 4 Prepare the insertion site with a burr or shaver.

preparation for the anchor insertion.

7. Anchor Insertion
A. Some small purely anterior or posterior SLAP lesions require only one anchor.
Most SLAP repairs require at least a double loaded anchor or 2 anchors, one
anterior and one posterior to the base of the biceps.
B. Anchor location should be on superior edge of the glenoid.
C. An approximate 45 degree angle to engage bone. Too shallow an angle will
delaminate the articular surface. Too steep angle will skive off the neck of the
8. Anterior anchor
A. Insert through the anterior superior portal, drill or tap
for anchor insertion.
B. Place either a small metal anchor or absorbable
anchor into position loaded with non-absorbable
suture (e.g. #2 ethibond or polyethylene).
C. Remove the inserter and pull on sutures to make sure
anchor is secure.
D. If a mid glenoid portal was established you may
retrieve the inferior suture limb through it now
(Figure 5). The other limb should remain in the
anterior superior portal.
Figure 5 Grab one limb of the suture
with a crochet hook through the midglenoid portal.

9. Passage Simple Stitch or first limb of Mattress Stitch

A. Using a crescent hook, suture lasso or a penetrating retriever through the anterior
superior portal, pierce the labrum, pull the suture back through the labrum and
then out the superior portal. An example, using a PDS shuttle technique, is shown
in figures 6 and 7.

Figure 6 Crescent hook through the anterior superior portal

Figure 7 Pierce the labrum, deploy the shuttle, and

grasp it through the mid-glenoid portal.

B. For a simple stitch, now tie the suture either using a sliding knot and a series of
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)

Figure 8 Grasp the second limb of suture with a crochet hook

from the mid-glenoid portal.

Figure 9 The crescent hook again pierces


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.

11. Double-Loaded Anchors

A. Some anchors come loaded with two sutures and the second suture can be also
used to reinforce the repair.
B. For suture management, one set of sutures needs to be parked outside the
superior cannula or in the mid-glenoid cannula.
12. Posterior Anchor Placement
A. The Port of Wilmington portal (Posterolateral portal) - 1 cm lateral, 1 cm
anterior to the posterior lateral corner of the acromion is used for insertion of
suture anchors for posterior portions of SLAP (figure2). This portal can be

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).

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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

Arthroscopic "Anterior" Stabilization

1. Examination under anesthesia. By pressing the humeral head into the glenoid and
translating the humerus anteriorly, posteriorly, and inferiorly, one can appreciate the
degree of laxity and whether or not the shoulder translates beyond the limits of the
glenoid. 2cm of inferior translation that does not reduce with external rotation
indicates severe rotator interval deficiency and is an indication for rotator interval
closure. As the arm is brought into moderate degrees of abduction external rotation,
engagement of Hill-Sachs lesions can be further appreciated as a crepitus or click.
Comparisons can be made with the opposite extremity.
2. Position the patient either in the lateral decubitus or beach chair position(lateral
position is usually preferred for labral reconstructions). Make sure head and neck are
well supported, axillary area and legs are padded.
3. Posterior portal developed with a needle stick 1-2cm posterior and inferior to the
posterior-lateral corner of the acromion. Shoulder is inflated with saline through a
spinal needle, followed by a puncture and introduction of a conical scope trocar.
Alternately, the cannula can be introduced with a conical trochar without preinflation.
4. Diagnostic Arthroscopy
Evaluate biceps tendon and anchor, followed by anterior labrum. Anterior
capsular ligaments superiorly(rotator interval), middle, and inferior
glenohumeral ligament. Visualize the inferior pouch followed by
posterior humeral head to identify chondral or impression defects on
the humeral head. Rotator cuff evaluation, supraspinatus, and
5. Develop anterior portal superiorly. Needle placed anterior-lateral to the
acromioclavicular joint, entering the interval just below the biceps tendon. A
switching stick is introduced, and the scope is placed through the anterior superior
portal. Visualize the labrum and glenoid articulation. Visualize glenoid articular
surface to see if bone erosion or loss. Rotate light cord to further visualize capsule
ligaments at the attachment to the humeral head with internal rotation. Capsule and
subscapularis insertion can be visualized. Visualize posterior labrum and orientation
of humeral head to glenoid. (Figure 1)

Figure 1: Left shoulder oriented in

lateral decubitus with two anterior
portals within the rotator interval and
posterior portal for viewing.

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).

Figure 2: Twin anterior portals outside view


Figure 3: Twin anterior portals viewed from post

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

Figure 4: Right shoulder. Elevator instrument

dissecting scarred labrum from glenoid neck.

8. Prepare glenoid neck. Shaver blade followed by gentle burr to debride devitalized
(Figure 3)

Figure 3: Left shoulder viewed from anterior portal. Shaver blade followed by gentle burring
the glenoid neck or tissue reattachment.


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).

Fig 4: 1cm Inferior capsular slit made

with a narrow basket punch

Fig 5: Split completed

Fig 6: Split advanced and


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)

Figure 7: Right shoulder. Capsular

plication with suture hook and
monofilament suture.

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.

12. Insert the inferior anchor below the articular surface.

13. There are many ways to pass the suture through the labrum. The most important
thing to remember is that the capsule must be shifted superiorly in order to
compensate for its plastic deformation prior to avulsion. Usually about 1.5cm of
shift is appropriate. Use the split-shift technique if needed. The suture for the first
anchor must therefore be retrograded through the labrum about 1.5 cm inferior to the
anchor so that the capsule will shift up to the anchor when the knot is tied.
14. Various devices are available to pass sutures such as a suture lassos, spectrum
suture hooks with either a commercial relay device or PDS loop. We show one
technique here with a curved Spectrum suture hook with a shuttle relay. Introduce
the suture hook through the inferior glenohumeral ligament inferior to the suture
anchor, approximately 8mm away from the edge. Supinate to rotate hook so that the
tip can be visualized while introducing the relay. (Figure 6)

Figure 6: Right shoulder. Spectrum

hook introducing shuttle inferior to
suture anchor.

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)

Figure 7: Right shoulder. Suture shuttle

transferring braided sutures under
labrum and through capsular ligament.

16. Tie a sliding knot through the

inferior cannula with the post
on the suture that has passed under the labrum and through the capsule. Push the knot
towards the suture anchor, advancing the soft tissue to the glenoid. Reduce any
traction on the shoulder prior to locking the knot. Follow any sliding knot with three
alternating half hitches. (Figure 8)

Figure 8: Right shoulder. Sliding knot

securing capsule and labrum to glenoid.

17. Place the middle suture anchor in a similar fashion.

18. Use the suture hook to advance the superior band of the inferior glenohumeral
19. Through the superior portal, retrieve the shuttle as well as one arm of the suture from
the anchor (avoid criss-crossing sutures).
20. Tie a sliding knot through the inferior cannula (second anchor).
21. Repeats steps for the superior anchor. With the scope posteriorly, visualize the
relationship of the Hill-Sachs lesion to the glenoid, making sure that it is posterior
and does not articulate with the glenoid. (Figure 9)

Figure 9: Left shoulder out of traction

testing posterior rotation of Hill-Sachs

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)

Figure 11: Posterior left shoulder.

Plication sutures using suture hook
grasping capsule and attaching to
labrum or capsular plications within
midsubstance of capsule.

Figure 12: Right shoulder x-ray showing

placement of anchors in glenoid.