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

Principles and Applied Principles and Applied Anatomy for Arthroscopic Anatomy for Arthroscopic

Anterior and Posterior Anterior and Posterior Instability Surgery of the Instability Surgery of the

ShoulderShoulder

Edward Tillett, M.D.Department of Orthopedic Surgery University of Louisville

Anterior and Posterior Anterior and Posterior InstabilityInstability

of the Shoulderof the Shoulder

• The loss of capsulolabral support on The loss of capsulolabral support on the anterior or posterior glenoidthe anterior or posterior glenoid

Anterior and Posterior Anterior and Posterior InstabilityInstability

Principles of Arthroscopic Principles of Arthroscopic Anterior and Posterior Anterior and Posterior

Instability RepairsInstability 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

Appropriate Portal Appropriate Portal PlacementPlacement

• Must allow access to the inferior Must allow access to the inferior aspect of the anterior and posterior aspect of the anterior and posterior glenoid for capsule and labrum glenoid for capsule and labrum mobilization and suture anchor mobilization and suture anchor placementplacement

Anterior Inferior PortalAnterior Inferior Portal

• Capsulolabral releaseCapsulolabral release

• Bone preparationBone preparation

• For low anterior suture anchor For low anterior suture anchor placement (5 o’clock position)placement (5 o’clock position)

*This portal is just *This portal is just superior to the superior to the subscapularis tendon and subscapularis tendon and should be angled enough should be angled enough for suture anchor for suture anchor placementplacement

Appropriate Location of Anterior Appropriate Location of Anterior Inferior PortalInferior Portal

Posterior Inferior PortalPosterior Inferior Portal

• Capsulolabral ReleaseCapsulolabral Release

• Bone PreparationBone Preparation

• For Low Posterior Suture Anchor For Low Posterior Suture Anchor Placement (7 o’clock position)Placement (7 o’clock position)

*This usually is the standard posterior *This usually is the standard posterior portal which is 2cm inferior and portal which is 2cm inferior and medial to the posterolateral border of medial to the posterolateral border of the acromiumthe acromium

Posterior Inferior PortalPosterior Inferior Portal

• 2 MRI**********2 MRI**********

Mobilize Anterior Capsule and Mobilize Anterior Capsule and LabrumLabrum

• Frequently, the capsule and labrum Frequently, the capsule and labrum heals in a medially displaced position heals in a medially displaced position on the glenoidon the glenoid

• Therefore, it should be released to Therefore, it should be released to the 6 o’clock position to allow it to be the 6 o’clock position to allow it to be advanced to the normal anatomic advanced to the normal anatomic positionposition


Mobilize Posterior Capsule and Mobilize Posterior Capsule and LabrumLabrum


Axillary Nerve AnatomyAxillary Nerve Anatomy

• The axillary nerve may be at risk when manipulating The axillary nerve may be at risk when manipulating tissue at the inferior aspect of the glenoid rim.tissue at the inferior aspect of the glenoid rim.

• Where is it?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


• The axillary nerve is closest to the The axillary nerve is closest to the glenoid rim at the 6 o’clock positionglenoid rim at the 6 o’clock position

• It lays about 12mm from the inferior It lays about 12mm from the inferior glenoid rim and is adjacent to the glenoid rim and is adjacent to the capsulecapsule



Prepare Bone for a Healing Prepare Bone for a Healing ResponseResponse

• Bone Should be decorticated on the Bone Should be decorticated on the medial scapular neck just off the medial scapular neck just off the glenoid rimglenoid rim

Appropriate Suture Anchor Appropriate Suture Anchor PlacementPlacement

• Suture Anchors should be placed up Suture Anchors should be placed up onto the glenoid rimonto the glenoid rim

• The most inferior suture anchors for The most inferior suture anchors for anterior and posterior instability anterior and posterior instability should be placed at the 5 or 7 o’clock should be placed at the 5 or 7 o’clock positionposition

Anterior Inferior Suture Anchor Anterior Inferior Suture Anchor PlacementPlacement

Posterior Inferior Suture Anchor Posterior Inferior Suture Anchor PlacementPlacement

Appropriate Suture Anchor Appropriate Suture Anchor PlacementPlacement

Suture Passage: Capsule and Suture Passage: Capsule and LabrumLabrum

• Suture is passed through Capsule and Suture is passed through Capsule and LabrumLabrum

• Will allow an adequate shift of tissue to a Will allow an adequate shift of tissue to a normal anatomic position on the glenoid rimnormal anatomic position on the glenoid rim

• The suture through the capsule and labrum The suture through the capsule and labrum should be placed inferior to the level of the should be placed inferior to the level of the suture anchorsuture anchor

• Suture shuttle using an accessory portal is Suture shuttle using an accessory portal is easiesteasiest

Anterior Suture Passage Anterior Suture Passage Through Through Capsule and LabrumCapsule and Labrum

Posterior Suture Passage Posterior Suture Passage Through Through Capsule and LabrumCapsule and Labrum

Suture Passage Through Capsule and Suture Passage Through Capsule and LabrumLabrum

Anterior Superior PortalAnterior Superior Portal

• This portal is at the superior aspect of the This portal is at the superior aspect of the rotator interval between the subscapularis rotator interval between the subscapularis and biceps tendonsand biceps tendons

• Used for the suture shuttleUsed for the suture shuttle

Anterior Superior PortalAnterior Superior Portal

Posterior Superior PortalPosterior Superior Portal

• This portal is about 2cm distal and This portal is about 2cm distal and anterior to the posterolateral border anterior to the posterolateral border of the acromiumof the acromium

Posterior Superior PortalPosterior Superior Portal

• 2 Arthro Pix******2 Arthro Pix******

Secure Knot TyingSecure Knot Tying

• Learn how to tie sliding knot and Learn how to tie sliding knot and half-hitch knotshalf-hitch knots

Fixation of Capsule and Fixation of Capsule and LabrumLabrum

*The labrum and capsule are shifted and fixed up on the glenoid rim.

Anterior Capsulolabral Anterior Capsulolabral Repair Repair

Posterior Capsulolabral Posterior Capsulolabral Repair Repair

Anterior and Posterior Labral Anterior and Posterior Labral RepairsRepairs

Documents

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