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Arthroscopic Repair of Posterior Bony Bankart Lesionand Subscapularis Remplissage

Colten Luedke, D.O., Stefan J. Tolan, M.D., and John M. Tokish, M.D.

Abstract: Posterior shoulder instability with glenoid bone loss has only a fraction of the prevalence of anterior instability.Unlike the latter, there is a paucity of literature regarding the treatment of posterior bony Bankart lesions and even lesswith concomitant reverse Hill-Sachs lesions. This combination of pathology leads to a difficult situation regarding treat-ment options. We present our technique for arthroscopic repair of a posterior bony Bankart lesion and reverse Hill-Sachslesion. The importance of proper portal placement cannot be overstated. By use of the lateral position and strategicallyplaced portals, the posterior bony Bankart lesion and attached labral complex were appropriately mobilized. We reducedthe glenoid bone, with the attached capsulolabral complex, to the glenoid rim and performed fixation using a knotlesssuture anchor. We then placed 2 double-loaded suture anchors into the reverse Hill-Sachs lesion. The sutures were passedcreating horizontal mattress configurations that were tied at the end of the procedure, effectively externalizing thehumeral head defect. Our technique results in satisfactory fragment reduction, as well as appropriate capsular tension, andeffectively prevents the reverse Hill-Sachs lesion from engaging.

one defects of the glenoid and humeral head can

Bresult in instability and recurrent dislocationbecause they alter the natural congruency and disruptthe inherent static stabilizers of the glenohumeral joint.1

In contrast to anterior instability, posterior instability isuncommon, accounting for only 2% to 12% of all thepatients with glenohumeral instability.2,3 Themechanism resulting in a posterior bony Bankart lesionis usually a traumatic event resulting in posteriortranslation of the humeral head with the armpositioned in flexion and adduction. This has been welldocumented in athletes, especially football players andweightlifters, in addition to patients with seizures andthose sustaining electric shock.4,5 Traumatic posteriorshoulder dislocations can lead to impression fractureson the anterior surface of the humeral head, known as“reverse Hill-Sachs lesions.” Depending on the size of

Steadman Hawkins Clinic of the Carolinas, Greenville Healthenville, South Carolina, U.S.A.ors report the following potential conflict of interest or source of.T. receives support from Arthrex, DePuy, and Mitek.

October 18, 2016; accepted January 23, 2017.correspondence to John M. Tokish, M.D., Steadman Hawkinse Carolinas, 200 Patewood Dr, Ste C-100, Greenville, SC 29615,ail: jtoke95@aol.comy the Arthroscopy Association of North America7/161014/$36.00doi.org/10.1016/j.eats.2017.01.016

Arthroscopy Techniques, Vol 6, No

the defect, the reverse Hill-Sachs lesion can engage onthe posterior glenoid rim with internal rotation leadingto subluxation or recurrent dislocation events. The mostcommon complication after posterior dislocation isrecurrent instability, with a 17.7% recurrence ratewithin the first year after dislocation. The risk is highestin patients who are aged less than 40 years, sustain thedislocation during a seizure, and have a large reverseHill-Sachs lesion (>1.5 cm3).5

There exists a general consensus that glenoid boneloss with recurrent instability should be treated byrestoring the articular surface anatomy. The techniqueused to treat reverse bony Bankart lesions, as well asdetermining when to add a reverse remplissage pro-cedure, remains controversial, however. Methodsincluding posterior iliac crest glenoid bone block, openrepair with internal fixation, and arthroscopic labralrepair have shown variable outcomes in the literature,and an algorithm based on the degree of bone loss isless concise than anterior glenoid bone loss.1,6-8

The purpose of this article is to describe our techniqueof restoring the glenoid articular surface by repairing alarge posterior bony Bankart lesion and eliminating anengaging reverse Hill-Sachs lesion using reverseremplissage of the subscapularis (Table 1, Video 1). Thisall-arthroscopic procedure avoids the morbidity of anopen technique or detachment of the subscapularis andallows one to address both the posterior bone loss orcapsulolabral pathology and an anterior engaging lesion.

3 (June), 2017: pp e689-e694 e689

Table 1. Surgical Pearls and Pitfalls

Glenoid bone loss should be accurately quantified.The surgeon should identify whether a reverse Hill-Sachs lesion

engages the posterior glenoid.It is critical to accurately place the portals.

The posterior portal should be made slightly more superiorly andlaterally than usualdthis allows the surgeon to work below theportal more easily.

A posterior portal that is too medial should be avoided.A spinal needle should be used to accurately place both anterior

portals within the rotator interval.The anterior-superior portal should enable easy access to thereverse Hill-Sachs lesion.

The accessory posterior-lateral portal should be made using aspinal needle and provide the exact trajectory needed to themost posterior-inferior position on the glenoid.

Failure to properly place the portals can lead to inadequate labrummobilization, inability to capture the capsule and labrum withsuture, and improper anchor positioning.

Viewing from the anterior-medial portal (in the interval) provides afull view of the posterior glenoid.

Placing the Liberator or other mobilizing instrument from theanterior-superior portal provides an excellent trajectory to theanterior and posterior labrum.

Careful mobilization is warranted. A pitfall to avoid is creating aradial tear with the sharp Liberator, creating 2 separate labralsegments.

Thorough mobilization of the labrum is paramount to a tension-freerepair.

A well-mobilized labrum should float up evenly with the glenoidedge.

Inadequate mobilization will prevent the labrum from reachingthe glenoid face, leading to suboptimal repair and potentialfailure of the stabilizing procedure.

A chevron-shaped drill guide should be used.This enables the guide to easily sit on the glenoid face under axial

load without slipping.Medial placement of the anchors on the glenoid neck should beavoided.

The surgeon should capture the capsule in addition to the labrumwith sutures.

If tying arthroscopic knots, the surgeon should ensure they are dockedon the side away from the articular cartilage to avoid abrasionto the humeral head.

Remplissage should be performed.The calcified layer within the reverse Hill-Sachs lesion should be

removed.Anchors should be placed at the periphery of the lesion.This allows the subscapularis to fill the lesion effectivelyexcluding it from the glenohumeral joint.

Placing the anchors medially within the defect will potentiallyallow the defect to continue engaging the glenoid.

e690 C. LUEDKE ET AL.

Surgical Technique

Step 1We perform shoulder procedures with the patient in

the lateral position with 10 lb of free-weight traction.After proper preparation and draping, we create ourposterior portal slightly more laterally and superiorlythan the standard portal. This not only provides goodvisualization but also enables us to use it as a workingportal that is appropriately positioned for access to the

posterior glenoid. It is much easier to use the sutureshuttle instrument below the cannula, hence ourreasoning for placing the portal slightly more superi-orly. A standard 4-mm 30� arthroscope is inserted.

Step 2After diagnostic arthroscopy identifying labral

pathology, we place both of our anterior portals. Thefirst is placed medially in the rotator interval (midg-lenoid portal), whereas the second cannula is locatedhigh and laterally within the interval (anterior-superiorportal) at this point (Fig 1). The 2 separate cannulasresemble a double-barrel configuration when viewedfrom the posterior portal.We then switch the arthroscope to visualize from the

anterior aspect, giving us an excellent view of theposterior bone loss. Specific attention is given to thedegree of posterior bone loss and size of the reverseHill-Sachs lesion, not to mention the presence orabsence of a reverse humeral avulsion of the gleno-humeral ligament (reverse HAGL). Figure 2 shows theposterior bone loss encountered in our patient.

Step 3While the surgeon is viewing from the anterior

portal, the posterior bony Bankart lesion with theattached capsulolabral complex is completely mobilizedfrom its most inferior to superior extent. We begin thismobilization from the anterior-superior portal with anangled Liberator (Arthrex, Naples, FL) (Fig 3). Oneshould be aware that if the appropriate angled deviceis not used, the labrum could be lacerated, creating aradial tear with 2 separate floating fragments. If thecapsulolabral complex is scarred too medially to reachfrom the anterior-superior portal, working from theposterior or posterolateral portal may allow furtheraccess medially. Once appropriate mobilization isobtained, the bony fragment and labrum will often“float” up to the level of the glenoid surface for atension-free repair.

Step 4Once the bone-labral complex is well mobilized, we

prepare the glenoid bone to improve healing. Using arasp (Arthrex) or motorized shaver, the surgeonremoves the calcified layer often covering the nativeglenoid bone and creates a bleeding bone bed to facil-itate healing. If using a shaver, the surgeon must avoidcausing iatrogenic glenoid bone loss.

Step 5At this point, we have mobilized the posterior bony

Bankart lesion and prepared a bleeding bone bed. Theposterior bony fragment is now reduced to its anatomicposition. If this cannot be accomplished withoutexcessive tension, additional mobilization is required.

Fig 1. Proper placement of our 2 separate anterior portals(midglenoid and anterior-superior) in the rotator interval isshown in a left shoulder, viewing from the posterior portal.The double-barrel configuration of the midglenoid portal(left) and anterior-superior portal (right) should be noted. (B,biceps; G, glenoid; S, subscapularis.)

Fig 2. Posterior glenoid bone loss with posterior subluxationof the humeral head is shown in a left shoulder, viewing fromthe posterior portal. (G, glenoid bone defect; H, humeral headsuperiorly.)

REPAIR OF POSTERIOR BONY BANKART LESION e691

Beginning inferiorly, we capture the bony fragment inaddition to the capsule using an Arthrex FiberLinksuture. This allows us to create a “luggage tag” stitch bysimply passing the single end through the loop andremoving tension. To provide better access to theinferior aspect, we place a traction stitch (Fig 4) aroundthe labrum at the midaspect of the glenoid. Often thiswill be used and placed in our second suture anchor.This pulls the inferior labrum taut and more superiorly,enabling easier passage of the most inferior suturethrough the capsule and inferior labrum. The surgeonplaces the drill guide through the accessory posterolat-eral portal (still viewing from anterior) at an optimaltrajectory and predrills for our knotless anchor. We findit more efficient to use the chevron-shaped drill guidebecause its wedge shape fits well on the glenoid edgeand decreases the chance of sliding off with axial load.We also recommend using a small cannula in theposterolateral portal to prevent soft-tissue bridges andto decrease the chance of creating multiple holes in thethin posterior capsule. At this point, the most inferiorFiberLink suture is loaded into a 2.9-mm SutureTakknotless anchor (Arthrex) and immediately placed inthe hole. Using knotless anchors, we leave approxi-mately 2 to 3 mm of slack between the anchor andlabrum to appropriately tension the repair after drivingin the anchor. Additional anchors are placed approxi-mately 5 mm apart by repeating the aforementionedsteps (Fig 5). We close the posterior portal with a sutureat the end of the case (Fig 6).

Step 6After repair of the posterior bony Bankart lesion, we

turn our attention to the reverse Hill-Sachs lesion(Fig 7). The camera is switched back to the posteriorportal. With the shaver or a curette (from anteriorly),we now remove the calcified layer covering the lesionto again create a bleeding bed of bone. With a spinalneedle, an accessory anterolateral portal is made underdirect visualization. A drill guide or punch is placedthrough the subscapularis, and one hole is placedmedially and another laterally within the reverse Hill-Sachs lesion. Two double-loaded 4.75-mm SwiveLockanchors (Arthrex) are then placed into the drill holes(Fig 8). Using a BirdBeak device (Arthrex), we captureall sutures (4 pairs total). The sutures are then tied in ahorizontal mattress fashion, pulling the subscapularisinto the defect. This effectively creates 2 horizontalmattress sutures medially and 2 laterally (Fig 9).

DiscussionTo date, there has been a paucity of literature accu-

rately establishing which posterior bone defects shouldbe managed with bony procedures, as well as the cor-relation between posterior bone loss and risk of redis-location. Algorithms on anterior bone loss have beenreported in the literature, however. These algorithmstake into account the degree of bone loss; location ofdefects; associated reverse Hill-Sachs lesions; andpatient age, activities, and medical factors such asunstable epilepsy.1

DeLong et al.9 reported in their systematic review onposterior shoulder instability that stabilization with

Fig 3. Mobilization of the posterior bony Bankart lesion fromthe medial glenoid (G) with a Liberator (Arthrex) in theposterior portal is shown in a left shoulder, viewing from theanterior-superior portal downward on the posterior labrum.

Fig 5. Three repair sutures with anchors at the glenoid (G) artic-ularmarginareshownina left shoulder,viewing fromtheanterior-superior portal toward the posterior labrum. (H, humeral head.)

e692 C. LUEDKE ET AL.

anchors results in fewer recurrences and revisions thananchorless repairs in young adults engaging in highlydemanding physical activity. Furthermore, the litera-ture has suggested that patients with posterior labraltears treated arthroscopically have good outcomes withrespect to stability, recurrence of instability, patientsatisfaction, return to sport, and return to previous levelof play.

Fig 4. In a left shoulder, viewing from the anterior-superiorportal, a traction stitch (arrow) is placed within the posteriorcapsulolabral complex, pulling the inferior labrum up. Thiseffectively results in a taut bed of tissue to facilitate passage ofthe suture lasso (Arthrex) through the capsulolabral complex.(G, glenoid; PL, posterior labrum.)

Our arthroscopic approach allows for improvedvisualization and avoids the surgical morbidity associ-ated with open arthrotomy (Table 2). The describedtechnique highlights the crucial role of proper portalplacement. The posterior portal is established slightlymore superiorly and laterally than usual to enable itsuse as a working portal and provide an optimal anglefor suture shuttling and anchor insertion. The double-barrel configuration of the anterior portals allows

Fig 6. Closure of the posterior portal entry through the pos-terior capsule (arrow) and repaired posterior labrum to theglenoid (G) is shown in a left shoulder, viewing from theanterior-superior portal.

Fig 7. In a left shoulder, viewing from the midglenoid portalprovides good visualization of the reverse Hill-Sachs lesion(RSH) on the anterior humeral head. (S, subscapularistendon.)

Fig 9. An excluded reverse Hill-Sachs lesion is shown in a leftshoulder, viewing from the midglenoid portal. The sub-scapularis (S) is tied into the defect by use of a horizontalmattress technique to provide a broad surface area forhealing.

Table 2. Advantages, Disadvantages, Risks, and Limitations ofTechnique

Advantages

REPAIR OF POSTERIOR BONY BANKART LESION e693

perpendicular access to the reverse Hill-Sachs lesion,provides an excellent view while the surgeon is work-ing posteriorly, and gives an excellent trajectory formobilization of the posterior labrum. In addition, ourremplissage technique differs from that of Krackhardtet al. in that we place 1 suture anchor medially and 1laterally into the defect.10 By doing so, a larger footprint

Fig 8. Two double-loaded 4.75-mm SwiveLock anchors(Arthrex) inserted into the reverse Hill-Sachs lesion areshown in a left shoulder, viewing from the midglenoid portal.These anchors are placed percutaneously within the reverseHill-Sachs lesion through the subscapularis tendon (S).

is established, which allows for a broader area of con-tact and an improved healing environment for thesubscapularis tendon. A doubleehorizontal mattress

Minimally invasive approaches facilitate recovery andrehabilitation.

The technique allows the surgeon to access the anterior, posterior,and inferior glenoid and Hill-Sachs lesion reliably andreproducibly.

Lateral positioning with traction allows easy access to the mostinferior aspect of the glenoid.

Percutaneous placement of the posterior anchor provides anoptimal trajectory for the most posterior-inferior anchorplacement.

DisadvantagesBony procedures such as Latarjet or posterior bone blockprocedures are technically difficult to perform.

There are some reports of a higher risk of failure with arthroscopiclabral repair.

There is a risk of neurovascular injury with the portals.Risks

Infection (<1%)StiffnessFailure of repairIatrogenic cartilage injuryNerve or vascular injury

LimitationsSurgeon experience is necessary to successfully carry out thetechnique arthroscopically.

Bone loss may preclude this technique depending on surgeonexperience. Preoperative assessment with computed tomographyand/or magnetic resonance imaging will provide insight into thedegree of bone loss.

e694 C. LUEDKE ET AL.

configuration also reduces strangulation of the tissueand possible tissue necrosis, as described by DeLonget al.9 and Koo et al.10 Using the subscapularis to fill thereverse Hill-Sachs lesion effectively externalizes thelesion and prevents engaging on the posterior-inferiorglenoid with internal rotation of the arm.Carefully scrutinizing advanced imaging such as

computed tomography and/or magnetic resonanceimaging provides better visualization of bone loss andmore accurate estimation of the degree of bone loss.This is particularly important for bone loss greater than20% in which posterior bone block procedures may berequired for stability. Limitations exist regarding ourtechnique. First, it is only reliable for smaller posteriorbony Bankart lesions. In lesions with a larger degree ofbone loss, the technique may not provide adequatestability, thus necessitating other bony procedures.Second, our case demonstrates an acute injury. Chroniclesions are more difficult to mobilize and may be healedin a medial position, requiring extensive mobilization.Finally, we suggest explaining to the patient that anopen procedure may be required if the reverse Hill-Sachs lesion or posterior bone loss is greater thanexpected. In conclusion, our technique offers concisearthroscopic management of a posterior bony Bankartlesion and moderate-sized reverse Hill-Sachs lesion andprovides immediate stability for an acute posteriordislocation of the shoulder.

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