Recurrent anterior dislocation/subluxation with failure of non-operative treatment; Young patients with recurrent instability; Generally >3 dislocations
Danger Structures
undefined - Exits quadrangular space posteriorly, courses anteriorly around surgical neck of humerus 5-7cm inferior to acromion, typically 2-3cm inferior to anterior glenoid rim at 6:00 position
undefined - Leaves brachial plexus and enters coracobrachialis muscle belly 3-8cm (mean 5cm) distal to coracoid tip; located medial to coracoid
undefined - Cephalic vein runs in deltopectoral groove; deltopectoral perforating vessels cross area of anterior portal
undefined - Forms anterior wall of shoulder joint; superior border is just inferior to coracoid; anterior portal traverses through rotator interval just superior to subscapularis upper border
undefined - Target of anchor fixation; anterior rim may be deficient from chronic instability or fracture
undefined - Passes through suprascapular notch deep to superior transverse scapular ligament, then around spinoglenoid notch posteriorly; supplies supraspinatus and infraspinatus
undefined - Passes anterior-medial to glenohumeral joint, 2-3cm medial to coracoid; gives rise to musculocutaneous (lateral cord) and axillary (posterior cord) nerves
Visual Atlas
No anatomy Images Yet
We're currently sourcing high-quality anatomy diagrams for this procedure.
Step-by-Step Technique
1
Patient Positioning and Examination Under Anesthesia (EUA): Beach chair position with head secured, arm free for full ROM. Alternatively, lateral decubitus with 10-15 lbs traction. Before prepping, perform EUA: compare side-to-side laxity with load-and-shift test (grade anterior translation 0-3), assess degree of anterior/inferior translation, document hyperlaxity. EXAM KEY: EUA allows assessment of true ligamentous laxity without patient guarding - differentiates structural instability from voluntary instability.
Surgeon's Tip
EXAM KEY: EUA allows assessment of true ligamentous laxity without patient guarding - differentiates structural instability from voluntary instability.
Danger Zone
Iatrogenic injury to adjacent structures
2
Mark Bony Landmarks and Portal Sites: Palpate and mark: acromion edges (anterior, lateral, posterior), AC joint, coracoid process, coracoacromial ligament. Mark posterior portal (2cm inferior, 2cm medial to posterolateral acromion), anterior portal (rotator interval lateral to coracoid), anticipated inferior portal. EXAM KEY: Accurate portal placement is foundation of successful arthroscopic stabilization - poor portals make surgery difficult or impossible.
Surgeon's Tip
EXAM KEY: Accurate portal placement is foundation of successful arthroscopic stabilization - poor portals make surgery difficult or impossible.
Danger Zone
Iatrogenic injury to adjacent structures
3
Establish Posterior Portal and Glenohumeral Joint Inspection: Infiltrate posterior portal site with 1:200,000 epinephrine for hemostasis. Make 1cm vertical incision. Use blunt trocar and cannula to enter joint through rotator interval, aiming anteriorly toward coracoid. Insert 30° arthroscope. Systematic 21-point inspection: (1) biceps anchor, (2) superior labrum, (3) articular cartilage - humeral head (Hill-Sachs lesion), (4) articular cartilage - glenoid (bone loss), (5) anterior labrum (Bankart lesion), (6) inferior labrum, (7) posterior labrum, (8) rotator cuff undersurface, (9) capsular laxity. EXAM KEY: Systematic inspection identifies all pathology - SLAP tears, cartilage damage, bone loss, capsular volume.
Surgeon's Tip
EXAM KEY: Systematic inspection identifies all pathology - SLAP tears, cartilage damage, bone loss, capsular volume.
Danger Zone
Skin necrosis from excessive tension
Damage to underlying structures
4
Establish Anterior Portal Through Rotator Interval: Use spinal needle from outside-in to localize ideal anterior portal position - aim for rotator interval between supraspinatus and subscapularis, 1cm lateral to coracoid tip. Visualize needle tip in joint arthroscopically. Make 1cm incision. Use switching stick, then insert cannula through interval. EXAM KEY: Anterior portal through rotator interval provides optimal angle for viewing anterior glenoid and working on labrum; stay lateral to coracoid to avoid neurovascular bundle.
Surgeon's Tip
EXAM KEY: Anterior portal through rotator interval provides optimal angle for viewing anterior glenoid and working on labrum; stay lateral to coracoid to avoid neurovascular bundle.
Danger Zone
Skin necrosis from excessive tension
Damage to underlying structures
5
Prepare Glenoid Neck for Labral Repair: Switch arthroscope to anterior portal to view glenoid face-on. Insert shaver and rasp through posterior portal. Gently mobilize Bankart lesion if it's ALPSA (medialized). Use motorized shaver to remove soft tissue from anterior glenoid neck from 5:30 to 2:00 position (right shoulder). Use arthroscopic rasp or burr to decorticate glenoid neck creating bleeding bone bed - remove 2-3mm of cortex without gouging deeply. EXAM KEY: Adequate glenoid neck preparation is critical for labral healing - must have bleeding bone bed, but excessive bone removal causes glenoid bone loss.
Surgeon's Tip
EXAM KEY: Adequate glenoid neck preparation is critical for labral healing - must have bleeding bone bed, but excessive bone removal causes glenoid bone loss.
Danger Zone
Iatrogenic injury to adjacent structures
6
Establish Anterior-Inferior Accessory Portal for Anchor Placement: Use spinal needle to localize ideal anterior-inferior portal for optimal angle to glenoid rim at 5:30 position. Aim for mid-glenoid level, just above subscapularis superior border. Visualize needle from anterior portal. Make 1cm incision. Use switching stick and cannula. EXAM KEY: This low anterior portal provides optimal angle for drilling into glenoid face perpendicular to articular surface - critical for secure anchor fixation.
Surgeon's Tip
EXAM KEY: This low anterior portal provides optimal angle for drilling into glenoid face perpendicular to articular surface - critical for secure anchor fixation.
Danger Zone
Skin necrosis from excessive tension
Damage to underlying structures
7
Place Inferior-Most Anchor (5:30 Position Right Shoulder): Insert drill guide through anterior-inferior portal, position on glenoid face at 5:30 position (right shoulder), 2-3mm medial to articular cartilage edge (on glenoid neck). Drill perpendicular to glenoid articular surface with arthroscopic drill to measured depth (typically 15-20mm). Insert bioabsorbable or PEEK suture anchor loaded with two #2 sutures. Ensure secure anchor purchase by pulling firmly. EXAM KEY: First anchor at 5:30 is most inferior - captures inferior glenohumeral ligament (IGHL) which is primary anterior stabilizer; position on bone just medial to cartilage edge, not on rim (prevents rim fracture).
Surgeon's Tip
EXAM KEY: First anchor at 5:30 is most inferior - captures inferior glenohumeral ligament (IGHL) which is primary anterior stabilizer; position on bone just medial to cartilage edge, not on rim (prevents rim fracture).
Danger Zone
Iatrogenic injury to adjacent structures
8
Pass Sutures Through Labrum and Capsule - Inferior Anchor: Use arthroscopic suture passer (penetrating device like Spectrum or BirdBeak) to pass one limb of suture through labrum and anterior capsule from inside (joint side) to outside (capsular side), 5-10mm lateral to labral tear edge. Retrieve suture and bring back into joint. Repeat with second suture limb, creating mattress configuration. EXAM KEY: Suture passage technique critical - must capture labrum AND capsule to restore anatomy; capsule-only repair fails to restore labral bumper; labrum-only doesn't tension capsule.
Surgeon's Tip
EXAM KEY: Suture passage technique critical - must capture labrum AND capsule to restore anatomy; capsule-only repair fails to restore labral bumper; labrum-only doesn't tension capsule.
Danger Zone
Iatrogenic injury to adjacent structures
9
Place Mid-Glenoid Anchor (4:00-4:30 Position) and Pass Sutures: Position drill guide on glenoid neck at 4:00-4:30 position, 2-3mm medial to cartilage edge. Drill perpendicular to articular surface. Insert second anchor. Pass sutures through labrum and capsule as described above, creating mattress configuration. EXAM KEY: Sequential anchor placement from inferior to superior restores labral height and tensions capsule appropriately; mid-glenoid anchor captures middle glenohumeral ligament (MGHL) complex.
Surgeon's Tip
EXAM KEY: Sequential anchor placement from inferior to superior restores labral height and tensions capsule appropriately; mid-glenoid anchor captures middle glenohumeral ligament (MGHL) complex.
Danger Zone
Iatrogenic injury to adjacent structures
10
Place Superior Anchor (3:00-2:00 Position) and Pass Sutures: Position drill guide at 3:00-2:00 position (biceps level), 2-3mm medial to cartilage. Insert third anchor. Pass sutures through superior labrum and capsule. May need fourth anchor if labral tear extends superiorly. EXAM KEY: Superior repair captures superior glenohumeral ligament (SGHL) and reinforces rotator interval; extent of superior dissection depends on labral pathology.
Surgeon's Tip
EXAM KEY: Superior repair captures superior glenohumeral ligament (SGHL) and reinforces rotator interval; extent of superior dissection depends on labral pathology.
Danger Zone
Iatrogenic injury to adjacent structures
11
Tie Sutures Sequentially from Inferior to Superior: Using arthroscopic knot-tying technique (sliding knot like SMC or non-sliding like Duncan loop), tie inferior-most sutures first. View labral reduction from anterior portal - ensure labral tissue restored to anatomic position on glenoid rim creating bumper effect. Advance knot to tissue with knot pusher, cinch down firmly. Back up with three additional half-hitches (RCHs). Cut sutures. Progress superiorly, tying each anchor's sutures sequentially. EXAM KEY: Sequential tying from inferior to superior allows progressive tissue tensioning; visualize labral reduction with each knot - should see labrum sealed to glenoid rim creating bumper that prevents anterior translation.
Surgeon's Tip
EXAM KEY: Sequential tying from inferior to superior allows progressive tissue tensioning; visualize labral reduction with each knot - should see labrum sealed to glenoid rim creating bumper that prevents anterior translation.
Danger Zone
Inadequate reduction
Iatrogenic fracture
12
Assess Repair Integrity and Perform Capsular Shift if Indicated: Probe repaired labrum to assess security of fixation. Perform dynamic examination: translate humeral head anteriorly with probe - should have firm endpoint with no translation beyond glenoid rim. If residual laxity or capsular redundancy (large capsular volume): perform capsular shift by imbrication - take larger bites of capsule with suture passage, or place additional plication sutures in mid-capsule. EXAM KEY: Adequate capsular tensioning prevents recurrence; goal is to eliminate pathologic laxity while preserving functional ROM (ER should be 30-40° at side).
Surgeon's Tip
EXAM KEY: Adequate capsular tensioning prevents recurrence; goal is to eliminate pathologic laxity while preserving functional ROM (ER should be 30-40° at side).
Danger Zone
Iatrogenic injury to adjacent structures
13
Address Hill-Sachs Lesion if Engaging (Remplissage): If Hill-Sachs lesion is 'off-track' (engaging with glenoid in functional position): perform remplissage to prevent engagement. Place 1-2 anchors into posterior-superior humeral head at Hill-Sachs lesion base. Pass sutures through infraspinatus tendon and posterior capsule. Tie, filling defect with soft tissue. EXAM KEY: Remplissage (French for 'filling') converts off-track Hill-Sachs to on-track by filling defect with infraspinatus; prevents engagement that causes recurrent instability; expect 5-10° ER loss.
Surgeon's Tip
EXAM KEY: Remplissage (French for 'filling') converts off-track Hill-Sachs to on-track by filling defect with infraspinatus; prevents engagement that causes recurrent instability; expect 5-10° ER loss.
Danger Zone
Iatrogenic injury to adjacent structures
14
Final Inspection and Portal Closure: Perform final systematic inspection of entire joint: confirm labral repair security, assess capsular tension, check for loose bodies or chondral defects, inspect rotator cuff. Test ROM: forward flexion, ER at 0° and 90° abduction, IR. Document final appearance with photographs/video. Remove all instruments and cannulas. Irrigate thoroughly. Close portals with 3-0 or 4-0 nylon simple sutures. Apply sterile dressing and sling. EXAM KEY: Final ROM check confirms adequate repair without over-tightening; should achieve 30-40° ER at side minimum; if less, consider releasing superior-most sutures.
Surgeon's Tip
EXAM KEY: Final ROM check confirms adequate repair without over-tightening; should achieve 30-40° ER at side minimum; if less, consider releasing superior-most sutures.