Shoulder arthroscopy is a type of surgery that uses a small camera (arthroscope) inserted through a small incision to examine or repair the tissues inside or around your shoulder joint. Shoulder Arthroscopy is recommended for shoulder problems such as:-

• A torn or damaged cartilage ring (labrum) or ligaments (in cases of shoulder instability)
  
  
• A torn or damaged biceps tendon
  
  
• A torn rotator cuff
  
  
• A bone spur or inflammation around the rotator cuff
  
  

Three types of shoulder surgery are performed depending on patient's condition. They are explained below:-

• Knotless Single Row Rotator Cuff Repair using the PushLock and FiberTape
  
  
• Stabilization of Acromioclavicular Joint Dislocation using the AC GraftRope System
  
  
• PushLock Bankart and SLAP Repair
  
  

Knotless Single Row Rotator Cuff Repair using the PushLock and FiberTape

The 4.5 mm PushLock can be combined with #2 FiberTape to provide an easy solution for the knotless repair of
small, nonretracted rotator cuff tears.

	Through a lateral portal, pass both ends of a #2 FiberTape through the tendon in an inverse mattress configuration, using a Scorpion™ Suture Passer. Use the anterior portal to aid suture management.
	Create a stab incision off the lateral edge of the acromion for the PushLock bone socket preparation and insertion. Retrieve both FiberTape tails through this portal and preload them through the PushLock eyelet. Punch through the same portal using the Punch for the 4.5 mm PushLock.
	Insert the PushLock through the stab incision and bring the eyelet to the edge of the bone socket. Leave approximately 20 mm of slack in the FiberTape to ease tensioning.
	Advance the driver into the bone socket until the anchor body makes contact with the bone. Evaluate tissue tension. Additional tension may be added by keeping a firm grip on the driver handle while pulling on each individual FiberTape tail.
	Using a mallet, tap the button on the driver until the laser line is flush with the humerus.
	Turn the driver handle counterclockwise six full turns to remove the driver. Cut the FiberTape tails flush using an open ended FiberWire cutter to complete the repair. It is best to cut each FiberTape tail individually.

Stabilization of Acromioclavicular Joint Dislocation using the AC GraftRope System

The AC GraftRope, another logical evolution of Graft Preparation the TightRope®, combines strength, simplicity, and a biologic component to address both chronic and acute acromioclavicular joint indications. With this system, an allograft or autograft is easily secured to the coracoid button and the unique cortical washer allows for Tenodesis Screw fixation of the graft to the clavicle. The metal clavicle washer and coracoid button are joined by a continuous loop of #5 FiberWire, providing fixation during the healing phase. This technique can be completed arthroscopically or open.

Intended Use

The AC GraftRope is intended for chronic and acute Grade IV-VI AC separations, as well as Type III separations per surgeon’s discretion.

Arthroscopic Surgical Technique

Place the patient in the lateral or beach chair position under a general anesthesia, supplemented with a scalene
block. Introduce the arthroscope into the glenohumeral joint via a standard posterior portal. Create an anterior
portal with an outside/in technique using a spinal needle to verify position. Insert an 8.25 mm cannula through
the anterior portal. Introduce a full radius shaver blade through the anterior cannula and work through the
rotator interval. Debride until the base of the coracoid can be visualized. Fully expose the inferior border of the
coracoid using a the shaver and OPES® RF probe. A 70° arthroscope may facilitate visualization and exposure of
the coracoid base.

Graft Preparation

An autograft or allograft semitendinosis, gracilis or tibialis is cleaned and prepped. The graft length should be approximately 12-15 cm, and the folded graft should pass through a 4.5-5.5 mm sizing block. If the graft is too wide, simply place the graft longitudinally on a graft board and use an #11 blade knife in-line with the tendon fibers to contour its width. The graft should be whipstitched on each of the free ends, and this can be simplified with a FiberLoop® or TigerLoop™. In order for there to be whipstitching inside the clavicle tunnel, it is important to begin stitching approximately 30 mm from the graft center point. When doubled over, the graft with whipstitching should easily pass through a 6 mm sizing block. Procedure-specific allografts prepared and sized to fit within the AC GraftRope product are available through Allograft Tissue Systems Inc. (ATSI).

	Remove the coracoid button and white FiberWire® suture labeled “Graft” from the package. Place the midpoint of 12-15 cm allograft or autograft over the button’s “basket handle.” Tie the graft suture over the graft, making sure to tie sufficient halfhitches. Cut suture leaving a 2 mm tail. Pull the whipstitched sutures and graft limbs through the clavicle washer. Keep graft/construct moist until implanted. Note: Make certain that the entire construct passes easily through a 6 mm sizing block.
	Drill a 2.4 mm unicortical hole in the clavicle at desired location, which is typically 35 mm from the distal clavicle. The drill hole should be placed in the center of the clavicle in the anterior to posterior plane. Leave pin in place. Ream unicortical 6 mm hole over the pin. Remove both pin and reamer. This will serve as pilot hole for AC guide placement.
	Position the AC TightRope® drill guide in the previously drilled clavicle pilot hole. Place the coracoid target on the inferior border of the base of the coracoid. The ideal location on the inferior coracoid is close to the base where it projects off of the glenoid. Make certain there will be sufficient bone bridges both anteriorly and posteriorly to the 6 mm reamed tunnel.
	Drill a 2.4 mm pin through the inferior cortex of the clavicle and through the coracoid. Leave the pin in position.
	Remove the drill sleeve and reposition the drill guide under the pin to keep it from advancing while reaming. Alternatively, the guide can be removed and a curette or open window of a shaver blade can be used to accomplish this. Use a 6 mm cannulated reamer over the pin and slowly ream through the clavicle and coracoid. Leave the reamer, but remove the inner guide pin.
	Pass the SD lasso wire through the reamer, making sure to keep the loop end up. Use a grasper to pull the lasso out of the anterior portal. Remove the cannulated reamer and load end of “Traction” (TigerWire) suture of the GraftRope construct into the SD lasso loop. Use the SD lasso loop to draw “Traction” suture through the clavicle and coracoid, and out the anterior portal.
	Pull “Traction” suture to deliver the coracoid button through the clavicle. Use a forked probe, suture retriever, or knot pusher to leverage the suture beneath the coracoid, while pulling on the suture from outside the anterior portal. This will facilitate delivery of the coracoid button and graft through the coracoid. Once the button is through the coracoid, use a probe to maneuver the button into the desired position at the coracoid base.
	Reduce the clavicle. While an assistant holds the clavicle reduced, tighten the #5 blue FiberWire. Use your index finger to “walk” the clavicle washer to the clavicle. Tie the washer down making sure to throw multiple half-hitches. Cut suture leaving adequate suture tails.
	Separate limbs of the graft and pull tight on both limbs. Place a 1.1 mm Nitinol wire through both cortices of the clavicle tunnel to act as a guide. Place a 5.5 mm Tenodesis Screw and Tenodesis driver over the guide wire and insert screw until flush.
	For final construct, cut the graft limbs at screw level, or consider running the limbs to the AC joint and securing them to the capsule with FiberWire, or anterior and posterior acromion with 3 mm SutureTaks.

 

PushLock Bankart and SLAP Repair

The PushLock is a knotless suture anchor designed for arthroscopic glenohumeral joint instability repair. The anchor provides the ability to independently pass the suture through a desired amount of tissue prior to anchor implantation. This feature allows the surgeon to properly capture the amount of capsule or labrum required for the pathology being treated. The unique two-piece PushLock design allows the surgeon to visualize and adjust tissue tension prior to final implant installation. The anchor is tapped into its final position and the sutures are cut flush.

The PushLock is available in 2.9 and 3.5 mm diameters. The body of the anchor is available in a bioabsorbable material, poly(L-lactide)acid (PLLA) and a nonabsorbable thermoplastic material, polyetheretherketone (PEEK). Both are strong, revisable and radiolucent implants, with no MRI artifact. Each version uses a PEEK eyelet for superior strength during insertion to allow firm tissue tensioning and shifting.

This guide will provide a stepwise approach to use the PushLock for Bankart and SLAP Repairs.

Patient Positioning

Patient positioning using the Beach Chair Lateral Traction Device or the Lateral Decubitus 3-Point Shoulder Distraction System allows for reliable joint distraction.

Bankart Surgical Technique

Portal Placement: Posterior Viewing Portal: Located approximately 2 cm inferior and 1 cm medial to the posterolateral corner of the acromion at the “soft” spot.

Anterosuperior Portal: Located through the superior margin of the rotator interval. This portal will be used for suture management. Insert a 5.75 mm Crystal Cannula®.

Anteroinferior Portal: Located as close as possible to the superior edge of the subscapularis tendon. This portal will be used for anchor placement. Insert a threaded 8.25 mm cannula.

	When significant scarring or an ALPSA (anterior labral periosteal sleeve avulsion) lesion is present, use a tissue elevator to mobilize and control the labrum. Create a bleeding bed using a Glenoid Rasp, mechanical shaver or arthroscopic burr to enhance tissue healing to bone
	Insert a curved SutureLasso™ SD (right curve for right shoulder) into the anteroinferior cannula and pass it through the capsulolabral tissue inferior to the intended position of the anchor. Advance the Nitinol wire loop into the joint. Retrieve the wire loop using a KingFisher® through the anterosuperior cannula.
Surgical Pearl: The suture shuttling step can be eliminated by using a FiberStick™ instead of the SutureLasso’s Nitinol wire loop. The FiberStick is a 50 inch, #2 FiberWire® with 12 inches stiffened. Replace the Nitinol wire loop with a FiberStick and advance it to the tip of the SutureLasso. Pass the SutureLasso through the capsulolabral tissue. Advance the FiberStick and directly retrieve it with a KingFisher through the anterosuperior cannula.
	Place 3 to 4 cm of #2 FiberWire suture through the Nitinol wire loop. Retract the wire loop, through the SutureLasso, to pull the FiberWire to the distal end of the SutureLasso inside the joint. Remove the SutureLasso and wire loop together to shuttle the FiberWire through the tissue.
	Retrieve both suture tails through the anteroinferior cannula. Pass the spear through the same cannula and place it on the glenoid rim at the desired position (typically 5 o’clock). The spear should be positioned superior to the previously passed FiberWire. The fish-mouth design of the spear allows it to remain securely on the corner of the glenoid. Create a bone socket for the anchor by advancing the step drill until its collar contacts the spear’s handle. If desired, a 1.5 mm offset guide can be used to obtain a more medial position onto the face of the glenoid.
	Thread the suture tails through the PushLock eyelet. Advance the driver into the joint, while maintaining tension on the suture tails. Tension the sutures to approximate the tissue to the eyelet and then advance both to the bone socket.
	Advance the PushLock into the bone socket, while releasing the suture tails, until the anchor body contacts bone. The labral tissue should be reduced to the glenoid rim. If the reduction is not optimal, back the driver out and correct the tissue tension by adjusting the slack in the suture prior to reinserting the anchor.
	Tap the button on the proximal end of the driver handle to advance the anchor body until the second laser line is flush with bone. Note: The button on the driver will not be flush with the back of the handle when the implant is fully seated. Remove the driver from the anchor by rotating it counterclockwise for six full revolutions
	Cut the sutures flush using an open-ended FiberWire Suture Cutter to minimize the chance for irritation occasionally seen following arthroscopically placed knots. Repeat steps 2-8 for each subsequent anchor.
SLAP Repair Portal Placement Posterior Viewing Portal: Location is the same as described for Bankart repair. Anterosuperior Portal: This portal can be used for anchor placement for SLAP lesions with a significant anterior extension and for suture management during repair of posterior SLAP lesions. Insert a 5.75 mm Crystal Cannula. Posterosuperior Lateral Acromial Portal (portal of Wilmington): A SLAP lesion with significant mid glenoid or posterior extension requires a portal located approximately 1 cm lateral and 1 to 2 cm anterior of the posterolateral corner of the acromion and penetrates the musculotendinous junction of the supraspinatus tendon. Use a spinal needle to localize the best anchor placement staying as medial as possible. Insert a 5.75 mm Crystal Cannula. Anteroinferior Portal: SLAP lesions with significant anterior extension could benefit from this portal for suture management.
	Posterior anchor placement: Replace the Nitinol wire loop in a Crescent SutureLasso SD with a FiberStick and advance it to the tip of the SutureLasso SD. Pass the SutureLasso SD through the superior labrum through the posterosuperior lateral acromial portal. Advance the FiberStick into the joint. Alternatively, load a free FiberWire into the tip of a BirdBeak® or SutureSnare™ and pass it directly through the labrum.
	Use a KingFisher to retrieve the FiberStick through the anterosuperior portal.
	Use the BirdBeak or SutureSnare to pass the other end of the FiberStick (located in the posterosuperior lateral acromial portal) through the labrum. Make sure that the suture is captured in the jaws of the BirdBeak. Keep the passes about 7-10 mm apart and form a horizontal mattress stitch. Retrieve the passed suture through the anterosuperior portal. Alternatively a single vertical mattress suture may be used.
	Pass the spear through the posterosuperior lateral acromial portal and place it on the glenoid rim. The fish-mouth design of the spear allows it to remain securely on the glenoid surface. Create a bone socket for the anchor by advancing the step drill through the spear until its collar contacts the spear’s handle. Remove the drill and spear. If desired, a 1.5 mm offset guide can be used to obtain a more medial position onto the face of the glenoid.
	Retrieve the FiberWire tails through the posterosuperior lateral acromial portal and thread them through the distal eyelet of the PushLock.
	Tension and advance the anchor into the bone socket as previously described in the Bankart surgical technique.
	Anterior anchor placement is similarly achieved.

Dr. Kevin Murphy, a nationally and internationally recognized orthopedic surgeon based in Jacksonville, Florida specializes in shoulder arthroscopy, upper extremities, hip arthroscopy, sports medicines, arthroscopic shoulder surgery and knee arthroscopy.