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Principles and Applied Anatomy for Arthroscopic Anterior and Posterior Instability Surgery of the Shoulder

Principles and Applied Anatomy for Arthroscopic Anterior and Posterior Instability Surgery of the Shoulder. Edward Tillett, M.D. Department of Orthopedic Surgery University of Louisville. Anterior and Posterior Instability of the Shoulder.

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Principles and Applied Anatomy for Arthroscopic Anterior and Posterior Instability Surgery of the Shoulder

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  1. Principles and Applied Anatomy for Arthroscopic Anterior and Posterior Instability Surgery of the Shoulder Edward Tillett, M.D. Department of Orthopedic Surgery University of Louisville

  2. Anterior and Posterior Instability of the Shoulder • The loss of capsulolabral support on the anterior or posterior glenoid

  3. Anterior and Posterior Instability

  4. Principles of Arthroscopic Anterior and Posterior Instability Repairs • Appropriate Portal Placement • Mobilize Capsule and Labrum • Prepare Bone for Healing Response • Appropriate Suture Anchor Placement • Suture Passage through Capsule and Labrum • Secure Knot Tying • Appropriate Fixation of Capsule and Labrum

  5. Appropriate Portal Placement • Must allow access to the inferior aspect of the anterior and posterior glenoid for capsule and labrum mobilization and suture anchor placement

  6. Anterior Inferior Portal • Capsulolabral release • Bone preparation • For low anterior suture anchor placement (5 o’clock position) *This portal is just superior to the subscapularis tendon and should be angled enough for suture anchor placement

  7. Appropriate Location of Anterior Inferior Portal

  8. Posterior Inferior Portal • Capsulolabral Release • Bone Preparation • For Low Posterior Suture Anchor Placement (7 o’clock position) *This usually is the standard posterior portal which is 2cm inferior and medial to the posterolateral border of the acromium

  9. Posterior Inferior Portal • 2 MRI**********

  10. Mobilize Anterior Capsule and Labrum • Frequently, the capsule and labrum heals in a medially displaced position on the glenoid • Therefore, it should be released to the 6 o’clock position to allow it to be advanced to the normal anatomic position

  11. Mobilize Anterior Capsule and Labrum

  12. Mobilize Posterior Capsule and Labrum

  13. Mobilize Anterior Capsule and Labrum

  14. Axillary Nerve Anatomy • The axillary nerve may be at risk when manipulating tissue at the inferior aspect of the glenoid rim. • Where is it? • “Determining the Relationship of the Axillary Nerve to the Shoulder Joint Capsule from an Arthroscopic Perspective” • By: M.R. Price, MD, MS, Edward D. Tillett, MD, Robert D. Acland, MD, and G. Stephen Nettleton, PhD Journal of Bone and Joint Surgery, October, 2004

  15. Axillary Nerve Anatomy • The axillary nerve is closest to the glenoid rim at the 6 o’clock position • It lays about 12mm from the inferior glenoid rim and is adjacent to the capsule

  16. Axillary Nerve Anatomy

  17. Axillary Nerve Anatomy

  18. Prepare Bone for a Healing Response • Bone Should be decorticated on the medial scapular neck just off the glenoid rim

  19. Appropriate Suture Anchor Placement • Suture Anchors should be placed up onto the glenoid rim • The most inferior suture anchors for anterior and posterior instability should be placed at the 5 or 7 o’clock position

  20. Anterior Inferior Suture Anchor Placement

  21. Posterior Inferior Suture Anchor Placement

  22. Appropriate Suture Anchor Placement

  23. Suture Passage: Capsule and Labrum • Suture is passed through Capsule and Labrum • Will allow an adequate shift of tissue to a normal anatomic position on the glenoid rim • The suture through the capsule and labrum should be placed inferior to the level of the suture anchor • Suture shuttle using an accessory portal is easiest

  24. Anterior Suture Passage Through Capsule and Labrum

  25. Posterior Suture Passage Through Capsule and Labrum

  26. Suture Passage Through Capsule and Labrum

  27. Anterior Superior Portal • This portal is at the superior aspect of the rotator interval between the subscapularis and biceps tendons • Used for the suture shuttle

  28. Anterior Superior Portal

  29. Posterior Superior Portal • This portal is about 2cm distal and anterior to the posterolateral border of the acromium

  30. Posterior Superior Portal • 2 Arthro Pix******

  31. Secure Knot Tying • Learn how to tie sliding knot and half-hitch knots

  32. Fixation of Capsule and Labrum *The labrum and capsule are shifted and fixed up on the glenoid rim.

  33. Anterior Capsulolabral Repair

  34. Posterior Capsulolabral Repair

  35. Anterior and Posterior Labral Repairs

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