Shoulder Instability: Soft-Tissue/Ligament Repair

Shoulder Instability: Soft-Tissue/Ligament Repair

This video is a cadaveric demonstration of an anterior labral repair using knotless all-soft suture anchors. Here, we have two views. One an exterior view, which shows a right cadaveric shoulder, the smaller view in the upper right-hand corner is the view of the arthroscopic camera that is placed in the posterior portal.

Focusing on the exterior view, we see two portals with cannulas in the front of the shoulder. As we get a close-up of the arthroscopic view, we see the glenoid socket to the left and the humeral head to the right. In addition, we can identify the long head of the biceps tendon and the undersurface of the rotator cuff tendons.

As the surgeon focuses on the anterior labrum, we see that it is torn. After the labrum tears, it can scar down, which makes it more difficult to repair. The surgeon often will use a tool called an elevator to help release the scar tissue and mobilize the labrum, allowing the surgeon to approximate the tissue back to its anatomic position.

Once the tissue is mobilized, the surgeon is ready to start the repair. The surgeon will introduce a drill guide and place it on the edge of the glenoid in proper orientation. A drill will then be placed through the center of the guide and a pilot hole will be created with the drill. With steady hands, the drill guide remains in position as the drill is removed.

The anchor is then introduced through the drill guide and malleted into position in bone. The drill guide and anchor inserter are now removed, leaving the anchor behind. You will notice the anchor has 3 strands of sutures coming out of the glenoid bone. The blue and white suture will be the repair suture that will be passed around the labral tissue and help secure it back to bone.

The black and white sutures are one long strand that is threaded through the anchor body. This suture will act as a shuttle for the repair suture later in the case. Now that the anchor is in bone, it is time to start passing sutures around the labral tissue. Next, the surgeon will use a wire-passing device referred to as a lasso. This pointed tool allows the surgeon to grab a bite of capsular and labral tissue just below where they place the anchor itself.

Once the metal tip has exited next to the glenoid bone, a flexible wire with a loop on the end is deployed. The surgeon will grab the wire loop out of the same portal as the repair suture. The surgeon will load the repair suture into the wire loop and remove the suture passing device and wire. This step passes the repair suture around the labral tissue.

Now that the repair suture is passed around the labral tissue, the surgeon must secure it within the anchor. To do this, the surgeon will load the repair suture into the looped end of the black and white shuttle suture, then pull the nonlooped end of the shuttle suture. This will bring the repair suture through the finger trap mechanism within the soft body of the anchor, securing the repair suture without the need for the surgeon to tie knots.

This mechanism ensures the repair suture is secured within the anchor and can be tightened to the surgeon's preference to bring the labral tissue back down to bone. Once satisfied with the tension, the surgeon will cut the free end of the suture. This process is then repeated multiple times until the entirety of the labral tear has been repaired.