Portal Placement for Shoulder Arthroscopy: Basic to Advanced William B. Stetson, MD

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1 Portal Placement for Shoulder Arthroscopy: Basic to Advanced William B. Stetson, MD 1. Cannulas Smooth Ribbed Lipped Partial Threaded Fully Threaded Flexible 5.75 mm, 6 mm, 7 mm & 8.25 mm x 7cm or 9 cm 2. Access You need a reliable way to insert cannulas at a proper working angle Use of a spinal needle for accurate placement Confirm cannula angle prior to insertion anchor placement suture passage Cannulas can also be used for storage and tying needs Use of a switching stick to maintain the portal 3. Flexible Cannulas Allow passage of larger instruments without the need for a large cannula Easily conform to curved instruments 5.75 mm x 7 cm clear cannula 7 mm x 7 cm flexible twist-in cannula 4. Anatomic Landmarks Supraclavicular fossa Acromion Clavicle Coracoid process AC joint Lateral orientation line where the posterior aspect of AC joint intersects the supraclavicular fossa. used for establishing a lateral portal for a subacromial decompression, arthroscopic rotator cuff repair, or conversion to a mini-open repair.

2 5. Use of Portals It is still considered arthroscopic surgery as long as you don t connect the portals Jim Esch, MD, speaking at an OLC course many years ago. General Needs: Viewing portal/s Working portal/s Anchor placement/suture portals Isolate suture to be tied or passed in working portals Anchor placement/suture portals may not need a cannula 6. Anatomic Considerations Anterior: Stay lateral to coracoid to avoid neurovascular bundle

3 Axillary artery Brachial plexus (Musculocutaneous nerve) Inferior: Stay up and away from the 6:00 position Lateral: Off posterior/lateral surface of humerus Medial: At base of Scapular Spine: Careful with Nevaiser portal into joint 7. Portal Placement Workhorse Portals: Posterior Portal - viewing portal at the inferior edge of infraspinatus/interval between infraspinatus and teres minor Anterior Superior Portal - working portal in the rotator interval near the AC joint - inside out or outside in technique

4 - useful as a working portal for rotator cuff repairs and for arthroscopic Mumford procedures Lateral Portal - subacromial working/viewing portal placed 2 cm lateral to the edge of the acromion in line with the lateral orientation line Hold the Arthrosocpe with Two Hands! Train your assistant to hold the arthroscope with two hands. This steadies the picture for the surgeon and allows the surgeon to use his two hands for precise anchor placement, suture management and knot tying. The arthroscope is in the posterior portal, the lateral portal is in line with the previous drawn lateral orientation line, and the anterior superior portal is near the AC joint. Accessory Portals midglenoid portal - Bankart repair anteroinferior portal (5:00)- low anchor placement Neviaser portal - RTC repair port of Wilmington posterior SLAP posteroinferior portal (7:00) - posterior Bankart Posterior Anterior 8. Portals for SLAP Repair Standard Posterior Portal

5 viewing portal Anterior Superior Portal Anterior Midglenoid Portal made at the leading edge of the subscapularis Arthroscope is in the posterior portal, with twin anterior working portals, the anterior superior portal (left) and the anterior midglenoid portal (right). Port of Wilmington posterior SLAP tears one cm lateral and one cm anterior to posterior lateral corner of acromion percutaneous spinal needle technique to find trajectory (as in all percutaneous access) thru cuff muscle for posterior SLAP anchor placement no cannula is necessary! The port of Wilmington is made one cm lateral and one cm anterior from the posterior lateral corner of the acromion. 9. Portals for Bankart Repair Standard Posterior Portal working portal Anterior Superior Portal

6 viewing portal Anterior Midglenoid Portal working portal for anchor placement Figure 1 Figure 2 Figure 1 - The arthroscope is in the anterior superior portal viewing inferiorly which enables one to see the anterior neck of the glenoid and the anterior labrum (left shoulder). Figure 2 By viewing from the anterior portal, this allows for proper placement of anchors at the edge of the articular surface (right shoulder). 10. Accessory Portals for Bankart Repair 5:00 Low Anterior Portal below subscapularis (Tibone) 7:00 Low Posterior Portal through or inferior to teres minor percutaneous or with small cannula posterior Bankart 11. Portals for the Subacromial Space Standard Posterior Portal Anterior Superior Portal

7 viewing portal working portal The arthroscopic cannula is inserted into the posterior portal, underneath the acromion. A switching stick is then placed through the cannula and out the anterior superior portal. A second cannula is then placed anteriorly and the assistant hold both cannulas end to end. The arthroscope is then placed posteriorly and the arthroscopic shaver is placed anteriorly, at the tip of the arthroscope. Careful debridement is then performed of the bursa to create a room with a view. 12. Portals for Rotator Cuff Repair Standard Posterior Portal viewing portal Anterior Superior Portal working portal near the AC joint Lateral Portal working portal and viewing portal 50 yard line

8 acromioplasty and rotator cuff repair repair large cannula (8.25 x 7mm or 9 mm): large instruments Posterior Anterior Some complex tears are best viewed from the lateral portal with the working cannulas placed both posterior (left) and anterior (right). 13. Accessory Portals for Rotator Cuff Repair Postero-lateral Viewing Portal especially useful to visualize anterior cuff tears Portal of Wilmington percutaneous anchor placement one cm lateral and one cm from the posterior corner of acromion spinal needle technique to find trajectory this can be modified and placed percutaneously anywhere along the lateral edge of the acromion depending on where the anchor needs to be placed no cannula necessary suture Parking

9 Anchor placement can be made percutaneously through the portal of Wilmington or anywhere off the lateral edge of the acromion depending on where anchor needs to be placed which is determined by the direction of the spinal needle. Modified Neviaser Portal rotator cuff repair portal passes thru trapezius from medial to lateral (notch) The modified Neviaser portal is located in the supraspinatus fossa slightly more medial to avoid injury to the suprascapular nerve and for easier passage of instruments through the rotator cuff from medial to lateral.

10 Suture Management A. Good suture management is a critical skill in arthroscopy shoulder surgery. To minimize suture breakage which occurs from fraying of sutures against sharp instruments or edges of canullas. If sutures are entangled then repeated manipulation of the sutures to unentangle them leads to suture abrasion and breakage. Sutures placed properly are more likely to slide well and result in more knot and loop security. Vast amounts of time can be saved when these techniques are mastered. This time results in decreased soft tissue swelling and better results. B. Basic Concepts: 1. Triangulation 2. Suture marker 3. Portal issues 4. Suture or anchor first techniques 5. Concept of inner and outer limbs C. Triangulation technique essential for cannula placement, suture marker and suture retrieval. A technique that will save time and is beneficial in large people is the following: 1. Visualize desired entry site with scope 2. Externally visualize from needle entry site 3. While looking at shoulder direct toward forward tip of scope 4. Confirm on scope monitor D. Suture marker technique 1. Correlate joint and bursal path. 2. Useful for partial RCT 3. 18G Spinal needle 4. Monofilament suture 5. Place suture outside cannula

11 E. Correlation of findings Bursa Joint F. Suture management 1. Frequently facilitated by 3rd portal a. 1 Scope, 2 instruments, 3 retrieval devices 2. Tie knots from portal from which anchors placed (unless anchor was inserted percutaneously) 3. Never place knot down canulla with more than 1 suture set G. Creating portals 1. Inside out 2. Outside in H. Suture first fixation: Using as an example Type II SLAP repair 1. Deride labrum 2. Prepare bony bed 3. Drill hole 4. Pass suture thru labrum 5. Pass anchor 6. Tie knot * With suture first technique, the anchor needs to be loaded on the "inside" suture limb (not through tissue) so it can be slid down cannula into bone. In contrast, the knot needs to slide down the "outside" suture limb to cinch down the tissue firmly to the anchor in bone.

12 I. Debride bony bed J. Drill Hole on Corner K. Suture through Labrum and Insert Anchor L. "Anchor First" Fixation: Using as an example a Type II SLAP

13 1. Prepare bony bed 2. Drill hole & insert anchor 3. Retrieve suture through tissue 4. Tie knots Anchor on Corner Grasp suture from the anchor Tie a knot

14 M. Knotless Anchor Knotless anchors are well suited for the lateral row in dual row rotator cuff repairs. They tend to roll the edges of the cuff down so that the cuff edges don t get caught on the lateral edge of the acromion and there are no lateral knots to get caught either. When tying knots for Bankart repair, it is possible to engage the labral tissue and roll it up onto the glenoid rim creating a soft tissue buttress. This is much more difficult with the knotless design. The length of the loop in the anchor is fixed and therefore a proper bite of tissue must be taken so that the proper tension will be applied to the suture when the anchor is seated to the proper depth. Too big a bite will result in difficulty in inserting the anchor subcortically without cutting through the tissue and too small of a bite will result in a loose repair. N. Dual or Triple Suture Anchor 1. Screw in 2. Rotator cuff 3. Different colors 4. Stress distributed over broader area 5. Necessitate a third cannula to park one or both sets of sutures (Neviaser portal) O. Super Sutures One of the long standing challenges of arthroscopic stabilization and rotator cuff repair procedures has been suture breakage. The newest generation of sutures has greatly reduced this problem. Each company has its variation in this area. All tend to be much stiffer than Ethilbond or braided polyester and suture ends are more proud. All require specialized suture cutters to cut the knots. Make sure that you have the proper cutters before you use these sutures. P. Blind Knot Cutter 1. Guillotine design 2. Prevents knot cut out 3. Works well when visualization poor 4. Rotator interval closure Q. Suture Shuttle Braided suture is too flexible to feed it through a suture hook device and therefore some sort of suture shuttle is passed through the suture hook first and used to retrieve the braided suture through the tissue. This can be a commercial suture shuttle (Linvatec) or there are various substitutes. Doubled over #2-0 prolene is an easy substitute but attention must be paid to the direction that the suture is passed. An easier way is to pass a #1 PDS suture through the tissue first and then tie the appropriate end around the braided suture with a simple knot. Various companies make devices such as the Arthrex bannana device which has a doubled nitinol wire in it. 1. Doubled over #2-0 prolene 2. Simple #1 PDS 3. Disposable versions

15 Arthroscopic Repair of a Type II SLAP Lesion 1. Patient Positioning A. Lateral decubitus position. 1. Pad all bony prominences. 2. Axillary roll if necessary. 3. Tilt patient approximately 20 degrees posterior to orient glenoid parallel to floor. 4. Keep head of patient clear of anesthesia so surgeon can access anterior portals. 5. Hypotensive anesthesia if medically appropriate (Systolic BP<90). 2. Shoulder Suspension A. Suspend arm with 10lbs of weight. B. Approximately 70 degrees of abduction. C. Approximately 15 degrees of forward flexion (Figure 1). Figure 1 Patient positioning in the lateral decubitus position 3. Outline Anatomical Landmarks (Figure 2) A. Supraclavicular fossa. B. Acromion. C. Clavicle. D. Coracoid process. E. Anterior Portal F. Posterior Portal G. Port of Willmington F i g Figure 2 Anatomical landmarks looking from posterior to anterior. 1. Establish Posterior Portal A. 1-2 cm inferior and 1-2 cm medial to posterolateral corner of the acromion.

16 B. Direct cannula toward the coracoid process anteriorly. 2. Establish Anterior Superior Portal A. Outside in technique is preferred. Insert 18 gauge needle into joint under direct visualization at correct entry point and angle. B. The intra-articular entry point should be directly below the biceps tendon. a. Incise skin. Follow with a blunt conical point switching stick. b. Push cannula of choice over switching stick. Use dilators over switching stick for larger screw in cannulas. 3. Complete Diagnostic Exam of the Glenohumeral Joint A. View from the posterior portal. B. View from the anterior superior portal. C. Special attention to the superior labrum. D. Assess other pathology including the rotator cuff, anterior and posterior labrum and biceps tendon. 4. You may establish a mid-glenoid (mid-anterior) portal if desired but this is only mandatory for more extensive anterior labral repair A. Outside in technique. B. Spinal needle enters 1.5 cm lateral and 1.5 cm inferior to tip of the coracoid process. C. Enters the joint at the superior (leading) edge of the subscapularis tendon. D. Establish a secure cannula (e.g. 8.5 mm threaded cannula) (Figure 3) 5. Creating a Type II SLAP Lesion A. In the laboratory, with the scope in the posterior portal, place a small liberator elevator through the anterior superior portal. B. Elevate the biceps attachment from the superior rim of the glenoid. Figure 3 Viewing from the posterior portal, two anterior cannulas. 6. Preparing the Insertion Site A. With the scope remaining in the posterior portal, place a small round burr ( mm) or shaver through the anterior superior portal. B. Lightly burr the superior glenoid tubercle in Figure 4 Prepare the insertion site with a burr or shaver.

17 preparation for the anchor insertion. 7. Anchor Insertion A. Some small purely anterior or posterior SLAP lesions require only one anchor. Most SLAP repairs require at least a double loaded anchor or 2 anchors, one anterior and one posterior to the base of the biceps. B. Anchor location should be on superior edge of the glenoid. C. An approximate 45 degree angle to engage bone. Too shallow an angle will delaminate the articular surface. Too steep angle will skive off the neck of the glenoid. 8. Anterior anchor A. Insert through the anterior superior portal, drill or tap for anchor insertion. B. Place either a small metal anchor or absorbable anchor into position loaded with non-absorbable suture (e.g. #2 ethibond or polyethylene). C. Remove the inserter and pull on sutures to make sure anchor is secure. D. If a mid glenoid portal was established you may retrieve the inferior suture limb through it now (Figure 5). The other limb should remain in the anterior superior portal. Figure 5 Grab one limb of the suture with a crochet hook through the midglenoid portal. 9. Passage Simple Stitch or first limb of Mattress Stitch A. Using a crescent hook, suture lasso or a penetrating retriever through the anterior superior portal, pierce the labrum, pull the suture back through the labrum and then out the superior portal. An example, using a PDS shuttle technique, is shown in figures 6 and 7. Figure 6 Crescent hook through the anterior superior portal Figure 7 Pierce the labrum, deploy the shuttle, and grasp it through the mid-glenoid portal. B. For a simple stitch, now tie the suture either using a sliding knot and a series of half-hitches. 10. Suture Passage Second Limb of Suture for Mattress Stitch

18 A. For a mattress stitch, grasp the other limb of the suture from the anterior superior portal through the mid-glenoid or superior portal with a crochet hook. (Figure 8) B. Using the crescent hook or angled penetrating retriever from the anterior superior portal, pierce the labrum about one cm from the previous suture limb. (Figure 9) Figure 8 Grasp the second limb of suture with a crochet hook the from the mid-glenoid portal. Figure 9 The crescent hook again pierces labrum. C. Retrieve the suture back through the labrum and out the superior portal. Now tie with a Revo knot, you cannot use a sliding knot with a mattress stitch as the suture does not slide well. (Figure 10) Figure 10 A mattress stitch is created and tied through the anterior superior portal. 11. Double-Loaded Anchors A. Some anchors come loaded with two sutures and the second suture can be also used to reinforce the repair. B. For suture management, one set of sutures needs to be parked outside the superior cannula or in the mid-glenoid cannula. 12. Posterior Anchor Placement A. The Port of Wilmington portal (Posterolateral portal) - 1 cm lateral, 1 cm anterior to the posterior lateral corner of the acromion is used for insertion of suture anchors for posterior portions of SLAP (figure2). This portal can be

19 QuickTime and a established percutaneously using the small insertion cannula for the specific anchor being employed. Use needle locaization to establish the portal at the appropriate position aiming toward the posterior-superior glenoid rim(figure 11). B. Drill/tap and insert the anchor as described for the anterior anchor. C. Retrograde the suture through the labrum using an angled hook or penetrating retriever inserted through the anterior-superior portal. The suture can also be retrograded through the labrum using a percutaneous posterior-lateral portal(figure 12). Photo - JPEG decom pres s or are needed to see this picture. figure 11 figure 12 D. Deliver both suture limbs into the anterior-superior portal and tie. Use a sliding knot if the sutures glide well, a Revo knot if they do not. 13. Evaluating the Repair A. After tying the knot, cut the sutures and evaluate the repair. B. Place a probe through the anterior superior portal and probe the superior labrum to make sure the repair is adequate. (Figure 13) Figure 13

20 Arthroscopic "Anterior" Stabilization 1. Examination under anesthesia. By pressing the humeral head into the glenoid and translating the humerus anteriorly, posteriorly, and inferiorly, one can appreciate the degree of laxity and whether or not the shoulder translates beyond the limits of the glenoid. 2cm of inferior translation that does not reduce with external rotation indicates severe rotator interval deficiency and is an indication for rotator interval closure. As the arm is brought into moderate degrees of abduction external rotation, engagement of Hill-Sachs lesions can be further appreciated as a crepitus or click. Comparisons can be made with the opposite extremity. 2. Position the patient either in the lateral decubitus or beach chair position(lateral position is usually preferred for labral reconstructions). Make sure head and neck are well supported, axillary area and legs are padded. 3. Posterior portal developed with a needle stick 1-2cm posterior and inferior to the posterior-lateral corner of the acromion. Shoulder is inflated with saline through a spinal needle, followed by a puncture and introduction of a conical scope trocar. Alternately, the cannula can be introduced with a conical trochar without preinflation. 4. Diagnostic Arthroscopy Evaluate biceps tendon and anchor, followed by anterior labrum. Anterior capsular ligaments superiorly(rotator interval), middle, and inferior glenohumeral ligament. Visualize the inferior pouch followed by posterior humeral head to identify chondral or impression defects on the humeral head. Rotator cuff evaluation, supraspinatus, and subscapularis. 5. Develop anterior portal superiorly. Needle placed anterior-lateral to the acromioclavicular joint, entering the interval just below the biceps tendon. A switching stick is introduced, and the scope is placed through the anterior superior portal. Visualize the labrum and glenoid articulation. Visualize glenoid articular surface to see if bone erosion or loss. Rotate light cord to further visualize capsule ligaments at the attachment to the humeral head with internal rotation. Capsule and subscapularis insertion can be visualized. Visualize posterior labrum and orientation of humeral head to glenoid. (Figure 1) Figure 1: Left shoulder oriented in lateral decubitus with two anterior portals within the rotator interval and posterior portal for viewing.

21 6. Replace the scope in the posterior portal and develop the anterior inferior portal. Needle is placed lateral to the coracoid, entering above the subscapularis tendon adjacent to the humeral head. An 8mm cannula can be placed(figures 1 and 2). Figure 2: Twin anterior portals outside view portal Figure 3: Twin anterior portals viewed from post 7. Capsular labrum mobilization. This is a very important step, otherwise the capsule cannot be tensioned appropriately. Elevator instrument placed between the labrum and the glenoid to elevate the soft tissues off of the glenoid neck anteriorly and inferiorly. An RF probe can also be used here effectively with less bleeding. (Figure 4) Figure 4: Right shoulder. Elevator instrument dissecting scarred labrum from glenoid neck. 8. Prepare glenoid neck. Shaver blade followed by gentle burr to debride devitalized tissue. (Figure 3)

22 Figure 3: Left shoulder viewed from anterior portal. Shaver blade followed by gentle burring the glenoid neck or tissue reattachment. to 9. Test mobility of capsular ligaments with a suture hook. If the capsule cannot be advanced superiorly by at least 1.5cm, consider a capsular split-shift. This will also tension the inferior and posterior capsule (figures 4,5,6). Fig 4: 1cm Inferior capsular slit made Fig 5: Split completed Fig 6: Split advanced and repair with a narrow basket punch completed 10. Without a split-shift, if an inferior pouch is identified, consider plication stitch in the mid substance of the inferior glenohumeral ligament. (Figure 7) Figure 7: Right shoulder. Capsular plication with suture hook and monofilament suture. 11. Drill holes for suture anchors along glenoid using a drill guide through the inferior cannula. Position a drill bit onto the anterior inferior surface of the glenoid, approximately 2mm into the joint from the articular edge. Create drill hole followed by second and third drill holes with 1cm spacing. (Figure 8)

23 Figure 8: Right shoulder viewing from anterior superior. Suture anchor drill holes on the articular cartilage margin. 12. Insert the inferior anchor below the articular surface. 13. There are many ways to pass the suture through the labrum. The most important thing to remember is that the capsule must be shifted superiorly in order to compensate for its plastic deformation prior to avulsion. Usually about 1.5cm of shift is appropriate. Use the split-shift technique if needed. The suture for the first anchor must therefore be retrograded through the labrum about 1.5 cm inferior to the anchor so that the capsule will shift up to the anchor when the knot is tied. 14. Various devices are available to pass sutures such as a suture lassos, spectrum suture hooks with either a commercial relay device or PDS loop. We show one technique here with a curved Spectrum suture hook with a shuttle relay. Introduce the suture hook through the inferior glenohumeral ligament inferior to the suture anchor, approximately 8mm away from the edge. Supinate to rotate hook so that the tip can be visualized while introducing the relay. (Figure 6) Figure 6: Right shoulder. Spectrum hook introducing shuttle inferior to suture anchor. 15. Shuttle a braided suture from the superior cannula under the labrum and through the capsular ligament exiting out the inferior cannula. This can also be performed with the scope anteriorly superiorly and utilizing the posterior cannula for shuttling sutures. (Figure 7)

24 Figure 7: Right shoulder. Suture shuttle transferring braided sutures under labrum and through capsular ligament. 16. Tie a sliding knot through the inferior cannula with the post on the suture that has passed under the labrum and through the capsule. Push the knot towards the suture anchor, advancing the soft tissue to the glenoid. Reduce any traction on the shoulder prior to locking the knot. Follow any sliding knot with three alternating half hitches. (Figure 8) Figure 8: Right shoulder. Sliding knot securing capsule and labrum to glenoid. 17. Place the middle suture anchor in a similar fashion. 18. Use the suture hook to advance the superior band of the inferior glenohumeral ligament. 19. Through the superior portal, retrieve the shuttle as well as one arm of the suture from the anchor (avoid criss-crossing sutures). 20. Tie a sliding knot through the inferior cannula (second anchor). 21. Repeats steps for the superior anchor. With the scope posteriorly, visualize the relationship of the Hill-Sachs lesion to the glenoid, making sure that it is posterior and does not articulate with the glenoid. (Figure 9)

25 Figure 9: Left shoulder out of traction testing posterior rotation of Hill-Sachs lesion. 22. Place the scope anteriorly and further visualize the Hill-Sachs lesion posterior to the glenoid with the arm out of traction and attempt rotation to visualize the concentric reduction of the humeral head. 23. Rotator interval closure in selected cases. The tightness of the closure depends on how superior you pass the suture through the interval capsule and the number of sutures placed. With the scope posteriorly, use a right suture hook on a right shoulder to grasp the superior border of the middle glenohumeral ligament. The hook can be passed through the superior capsular ligament posterior to the biceps. Introduce a suture and tie. A reverse suture hook can then be introduced through the large cannula behind the biceps, grasping full-thickness superior glenohumeral ligament and followed by middle capsule ligament. The sutures can be placed sequentially from the glenoid edge to the lateral-placed cannula. (Figure 10) Figure 10: Left shoulder. Suture hook introducing grasping middle glenohumeral ligament and superior glenohumeral ligament behind the biceps closure of the interval as knots are tied.

26 24. Additional plication sutures can be used to balance the repair and center the humeral head as needed. Options include the posterior band of the inferior glenohumeral ligament, inferior or anterior capsular pouches. Plication sutures are placed with the suture hook approximately 1.5cm from the glenoid labrum, a full-thickness capsular bite is made. The hook is drawn superiorly, and a second pass of the hook is placed under and through the labrum. A monofilament suture is passed as the suture is tied, creating a pleating effect of the ligament against the glenoid. The option for a shuttle followed by a braided suture in cases where a permanent stitch is preferred. This is best utilized when the labrum is intact to the glenoid and therefore serves as a suture anchor. (Figure 11) Figure 11: Posterior left shoulder. Plication sutures using suture hook grasping capsule and attaching to labrum or capsular plications within midsubstance of capsule. Figure 12: Right shoulder x-ray showing placement of anchors in glenoid.