- Email: [email protected]
Arthroscopic posterior portal closure
Technical Note
Arthroscopic Posterior Portal Closure Alberto G. Schneeberger, M.D., and Edward H. Yian, M.D.
Abstract: Posterior “working” portals in arthroscopic posterior stabilization could result in defects of the posterior capsule if not repaired. We describe a single portal technique used to close the posterior portal defect after arthroscopic stabilization. It is a safe and easy-to-perform technique, which could strengthen the structural integrity of the repair. Key Words: Shoulder arthroscopy— Instability—Capsular repair—Portal closure.
A
rthroscopy of the shoulder has become an important tool for addressing shoulder instability. Initially used for anterior instability, its use has been recently described for posterior instability.1-6 Arthroscopic posterior stabilization requires posterior portals in an area where the capsule often is thin and of poor quality. Working portals using cannulas can cause tissue defects up to 9 mm in diameter. Certain techniques require an accessory posterior portal, which can create an additional defect.7,8 Such defects could compromise the quality of the repair. We describe an arthroscopic technique that allows closure of the posterior portal after addressing posterior pathology.
by the “working” portal after posterior stabilization, the posterior cannula is slightly withdrawn just outside to the capsule. A 30° curved Spectrum suture passer (Linvatec, Largo, FL) is placed through the posterior cannula, and then through the posterior labrum and the attached capsule. A no. 1 PDS suture is passed into the glenohumeral joint (Fig 2). The Spectrum suture passer is withdrawn from the cannula, leaving the suture in the joint. A 60° Suture Grasper (Mitek, Westwood,
OPERATIVE TECHNIQUE Arthroscopic posterior stabilization is performed though the posterior “working” portal using a cannula approximately 8 to 9 mm in diameter. The “viewing” portal with the camera is at an anterosuperior position (Fig 1). To close the posterior capsular defect caused
From Balgrist, Department of Orthopaedic Surgery, University of Zurich, Zurich, Switzerland. This study has been supported by the ResOrtho Foundation, Zurich, Switzerland. Address correspondence and reprint requests to Alberto G. Schneeberger, M.D., Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland. E-mail: [email protected] © 2004 by the Arthroscopy Association of North America 0749-8063/04/2006-3863$30.00/0 doi:10.1016/j.arthro.2004.04.028
110
FIGURE 1. Arthroscopic view from anterosuperior to the posterior “working” portal. (1) Humeral head subluxed inferiorly. (2) Glenoid. (3) Knotted suture with plication and fixation of the posteroinferior capsule to the posteroinferior labrum (4) as part of the posterior stabilization. (5) Posterior “working” cannula.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 20, No 6 (July-August, Suppl 1), 2004: pp 110-112
ARTHROSCOPIC POSTERIOR PORTAL CLOSURE
FIGURE 2. “Working” cannula slightly withdrawn just outside to the posterior capsule. Defect of the capsule marked with asterisks. (1) 30° curved Spectrum suture passer (Linvatec) placed through the posterior cannula and then through the posterior labrum. (2) A no. 1 PDS suture is passed into the glenohumeral joint.
MA) is inserted through the posterior cannula, penetrating the capsule of the opposite side of the defect distant to the posterior labrum (Fig 3). The PDS suture end is retrieved and withdrawn through the posterior cannula with the Mitek Suture Grasper (Fig 4). The two suture ends are tensioned and tied at the extracapsular side using the Duncan’s Loop9 (Fig 5). The cannula is removed and a “blind” knot cutter (Arthrex, Naples, FL) is used to cut the suture ends.
FIGURE 3. (1) Mitek Suture Grasper passed through the posterior cannula and through the posterior capsule at the opposite site of the defect. The no. 1 PDS suture (2) is retrieved. Defect of the capsule marked with asterisks.
111
FIGURE 4. Mitek Suture Grasper removed from the joint. (1) No. 1 PDS suture grasping the posterior labrum (2) and the capsule at the opposite side of the defect (3), which is marked with asterisks.
In cases with lack of the posterior capsule and labrum at the glenoid rim at the side of the defect, capsule-to-labrum closure is not possible. In this situation, a suture anchor is placed into the posterior glenoid rim through the posterior “working” portal. The post suture thread is withdrawn through the “working” cannula, and the thread on the opposite side is retrieved with the Mitek Suture Grasper as described here. The knot is completed. The significance of posterior capsular defects caused by cannulas is unknown. In other areas of the shoulder such as the rotator interval, arthroscopic closure techniques have been described.10 Defects of the
FIGURE 5.
Tissue defect closed by tying the suture (1).
112
A. G. SCHNEEBERGER AND E. H. YIAN
capsule could affect the quality of the repair, and closure of such defects seems, therefore, to be logical. We present this technique as an optional tool to optimize the repair. Further studies are needed to validate its significance. REFERENCES 1. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of multidirectional glenohumeral instability: 2 to 5 years follow up. Arthroscopy 2001;17:236-243. 2. Treacy SH, Savoie FH, Field LD. Arthroscopic treatment of multidirectional instability. J Shoulder Elbow Surg 1999;8: 345-350. 3. Antoniou J, Duckworth DT, Harryman DT II. Capsulolabral augmentation for the management of posteroinferior instability of the shoulder. J Bone Joint Surg Am 2000;82:1220-1230.
4. Wolf EM, Easkin CL. Arthroscopic capsular plication for posterior shoulder instability. Arthroscopy 1998;14:153-163. 5. Mair SD, Zarzour RH, Speer KP. Posterior labral injury in contact athletes. Am J Sports Med 1998;26:753-758. 6. Laurencin CT, Palleta GA, Potter H, Wickiewicz TL. Disruption of the posterior–lateral shoulder capsule. J Shoulder Elbow Surg 1995;4:391-394. 7. Davidson PA, Rivenburgh DW. The 7 o’clock posteroinferior portal for shoulder arthroscopy. Am J Sports Med 2002;30: 693-696. 8. Difelice GS, Williams RJ III, Cohen MS, Warren RF. The accessory posterior portal for shoulder arthroscopy: Description of technique and cadaveric study. Arthroscopy 2001;17: 888-891. 9. Sosin M, Kreh L. Practical Fishing Knots 11. New York: Lyons & Burford, 1991:59-60. 10. Karas S. Arthroscopic rotator interval repair and anterior portal closure: An alternative technique. Arthroscopy 2002;18:436439.
Arthroscopic Posterior Portal Closure Alberto G. Schneeberger, M.D., and Edward H. Yian, M.D.
Abstract: Posterior “working” portals in arthroscopic posterior stabilization could result in defects of the posterior capsule if not repaired. We describe a single portal technique used to close the posterior portal defect after arthroscopic stabilization. It is a safe and easy-to-perform technique, which could strengthen the structural integrity of the repair. Key Words: Shoulder arthroscopy— Instability—Capsular repair—Portal closure.
A
rthroscopy of the shoulder has become an important tool for addressing shoulder instability. Initially used for anterior instability, its use has been recently described for posterior instability.1-6 Arthroscopic posterior stabilization requires posterior portals in an area where the capsule often is thin and of poor quality. Working portals using cannulas can cause tissue defects up to 9 mm in diameter. Certain techniques require an accessory posterior portal, which can create an additional defect.7,8 Such defects could compromise the quality of the repair. We describe an arthroscopic technique that allows closure of the posterior portal after addressing posterior pathology.
by the “working” portal after posterior stabilization, the posterior cannula is slightly withdrawn just outside to the capsule. A 30° curved Spectrum suture passer (Linvatec, Largo, FL) is placed through the posterior cannula, and then through the posterior labrum and the attached capsule. A no. 1 PDS suture is passed into the glenohumeral joint (Fig 2). The Spectrum suture passer is withdrawn from the cannula, leaving the suture in the joint. A 60° Suture Grasper (Mitek, Westwood,
OPERATIVE TECHNIQUE Arthroscopic posterior stabilization is performed though the posterior “working” portal using a cannula approximately 8 to 9 mm in diameter. The “viewing” portal with the camera is at an anterosuperior position (Fig 1). To close the posterior capsular defect caused
From Balgrist, Department of Orthopaedic Surgery, University of Zurich, Zurich, Switzerland. This study has been supported by the ResOrtho Foundation, Zurich, Switzerland. Address correspondence and reprint requests to Alberto G. Schneeberger, M.D., Balgrist, Forchstrasse 340, CH-8008 Zurich, Switzerland. E-mail: [email protected] © 2004 by the Arthroscopy Association of North America 0749-8063/04/2006-3863$30.00/0 doi:10.1016/j.arthro.2004.04.028
110
FIGURE 1. Arthroscopic view from anterosuperior to the posterior “working” portal. (1) Humeral head subluxed inferiorly. (2) Glenoid. (3) Knotted suture with plication and fixation of the posteroinferior capsule to the posteroinferior labrum (4) as part of the posterior stabilization. (5) Posterior “working” cannula.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 20, No 6 (July-August, Suppl 1), 2004: pp 110-112
ARTHROSCOPIC POSTERIOR PORTAL CLOSURE
FIGURE 2. “Working” cannula slightly withdrawn just outside to the posterior capsule. Defect of the capsule marked with asterisks. (1) 30° curved Spectrum suture passer (Linvatec) placed through the posterior cannula and then through the posterior labrum. (2) A no. 1 PDS suture is passed into the glenohumeral joint.
MA) is inserted through the posterior cannula, penetrating the capsule of the opposite side of the defect distant to the posterior labrum (Fig 3). The PDS suture end is retrieved and withdrawn through the posterior cannula with the Mitek Suture Grasper (Fig 4). The two suture ends are tensioned and tied at the extracapsular side using the Duncan’s Loop9 (Fig 5). The cannula is removed and a “blind” knot cutter (Arthrex, Naples, FL) is used to cut the suture ends.
FIGURE 3. (1) Mitek Suture Grasper passed through the posterior cannula and through the posterior capsule at the opposite site of the defect. The no. 1 PDS suture (2) is retrieved. Defect of the capsule marked with asterisks.
111
FIGURE 4. Mitek Suture Grasper removed from the joint. (1) No. 1 PDS suture grasping the posterior labrum (2) and the capsule at the opposite side of the defect (3), which is marked with asterisks.
In cases with lack of the posterior capsule and labrum at the glenoid rim at the side of the defect, capsule-to-labrum closure is not possible. In this situation, a suture anchor is placed into the posterior glenoid rim through the posterior “working” portal. The post suture thread is withdrawn through the “working” cannula, and the thread on the opposite side is retrieved with the Mitek Suture Grasper as described here. The knot is completed. The significance of posterior capsular defects caused by cannulas is unknown. In other areas of the shoulder such as the rotator interval, arthroscopic closure techniques have been described.10 Defects of the
FIGURE 5.
Tissue defect closed by tying the suture (1).
112
A. G. SCHNEEBERGER AND E. H. YIAN
capsule could affect the quality of the repair, and closure of such defects seems, therefore, to be logical. We present this technique as an optional tool to optimize the repair. Further studies are needed to validate its significance. REFERENCES 1. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of multidirectional glenohumeral instability: 2 to 5 years follow up. Arthroscopy 2001;17:236-243. 2. Treacy SH, Savoie FH, Field LD. Arthroscopic treatment of multidirectional instability. J Shoulder Elbow Surg 1999;8: 345-350. 3. Antoniou J, Duckworth DT, Harryman DT II. Capsulolabral augmentation for the management of posteroinferior instability of the shoulder. J Bone Joint Surg Am 2000;82:1220-1230.
4. Wolf EM, Easkin CL. Arthroscopic capsular plication for posterior shoulder instability. Arthroscopy 1998;14:153-163. 5. Mair SD, Zarzour RH, Speer KP. Posterior labral injury in contact athletes. Am J Sports Med 1998;26:753-758. 6. Laurencin CT, Palleta GA, Potter H, Wickiewicz TL. Disruption of the posterior–lateral shoulder capsule. J Shoulder Elbow Surg 1995;4:391-394. 7. Davidson PA, Rivenburgh DW. The 7 o’clock posteroinferior portal for shoulder arthroscopy. Am J Sports Med 2002;30: 693-696. 8. Difelice GS, Williams RJ III, Cohen MS, Warren RF. The accessory posterior portal for shoulder arthroscopy: Description of technique and cadaveric study. Arthroscopy 2001;17: 888-891. 9. Sosin M, Kreh L. Practical Fishing Knots 11. New York: Lyons & Burford, 1991:59-60. 10. Karas S. Arthroscopic rotator interval repair and anterior portal closure: An alternative technique. Arthroscopy 2002;18:436439.