Labral repair surgery, explained by Ohio State Sports Medicine

Labral repair surgery, explained by Ohio State Sports Medicine


Here is our set up for a labral repair. The patient is in the lateral position with
the arm abducted and suspended in traction. We again draw our landmarks, and we locate
the glenohumeral joint. We confirm the position of the joint line from posterior with our
spinal needle. We take our scalpel and make an incision. And then we insert our blunt, metal trocar
into the joint. And then, once we are in the joint, we feel a nice pop through the posterior
capsule. We place the arthroscopic camera through the
cannula. We immediately create our anterior portal,
localizing with a spinal needle, and we view the spinal needle inside the joint just above
the subscapularis. We make our skin incision, and then we use
a metal trocar in the same position as a spinal needle, for in labral repairs it is very important
to confirm our angle of approach. We then slide our cannula down over this metal
stick. We insert our probe to evaluate the labral pathology. Remember, we are viewing
from posterior, we are probing the anterior labrum, which as we move inferiorally on the
glenoid, you can clearly see our Bankart lesion. The anterior inferior labrum is torn off of
the anterior inferior glenoid rim. Notice the tattering of the glenoid cartilage where
the labrum is attached. We now view the capsule in the axillary pouch,
which is clearly attached to the humeral head. We bring our camera up the back of the glenoid,
viewing the posterior inferior labrum. We then come up the back of the glenoid to
visualize the biceps tendon, which looks quite nice. We then turn our camera so that we may
visualize the rotator cuff attachment, which is nicely seen with a nice in-tact insertion
onto the humeral head. We now must prepare our glenoid for the repair.
The detached labrum is often scarred down medially to the anterior aspect of the glenoid.
We must free this up completely with our shaver so that the labrum is mobile for repair. Our
goal is to place the shaver between the labrum and the anterior glenoid, releasing all scar
tissue. This is very important to mobilize the labrum
for an anatomic repair. This is our Liberator elevator instrument
shaped like a spatula. This helps also elevate the labrum from its scarred position to the
glenoid. Remember, if we were to repair the labrum in a medial position, the repair is
likely to fail. We then use a shaver again to assure we are
freed up and to also create a bleeding surface along the anterior glenoid for later healing. We must now create our important anterior
superior portal, just anterior to the long head of the biceps, again with a spinal needle. We then use our metal switching stick, as
this eases the insertion of the cannula into the joint. We next place our camera in this anterior
superior portal to view the glenoid from this superior position. We are looking down on
the face of the glenoid, the Bankart is to the left, and we use our elevator one last
time to completely free the labrum, along with our shaver to ensure complete mobility
of the Bankart lesion. You can clearly see the anterior glenoid bone
to the right of the shaver and the Bankart lesion to the left. At this point, it is quite
mobile and the bone is nicely prepared. We are now ready to repair our Bankart lesion.
We use this metal curved piercer, a suture shuttling type device, to take a nice big
bite in the anterior inferior labrum. We then pass a sturdy suture for later shuttling through
the labrum. Once the suture is passed, we remove our piercer
device, and then we place the camera back into the posterior portal. We are ready now to
place our first anchor. Through our anterior portal, we place this
metal trocar as inferior as possible onto the glenoid rim. We create a pilot hole with
the punch, which is placed through this metallic trocar. We then remove the punch and use our bone
tap to prepare for the screw-in anchor. As this young male has very hard bone, we must
thoroughly tap the bone or our anchor could break. We then place and seat our bioabsorbable anchor
into the prepared spot as a small piece of cartilage floats around the joint trying to
obscure our view. This anchor is double loaded as you will see,
with two sutures, and we retrieve three of the sutures through our anterior superior
cannula to avoid tangling, which is very important in arthroscopic repairs. Outside the cannula, we tie our sturdy dark
blue Prolene suture to our white suture from the anchor. We pull on the opposite end of
the blue Prolene to shuttle our white suture through the labrum. We then retrieve its white mate through the
same anterior cannula so we can tie our first knot. Remember, these sutures are anchored into
the bone and one is through a nice, big bite of the labrum. As we pull down our sliding
knot, watch how the labrum is brought up nicely to the glenoid face. We use our knot pusher
to tighten and cinch down our knot. We then place a few extra knots on top to
completely secure our repair. We then cut our strands with a suture cutter
and we are ready to move on to the blue sutures. This next device is called a suture lasso.
This again pierces the labrum, taking a big bite. But we shuttle a loop out of the lasso.
We pull this loop out our anterior superior cannula and one of the blue sutures is placed
in the loop and then pulled back out the anterior cannula, shuttling through the labral tissue. We again tie our sliding knot and we reinforce
this with multiple extra knots with our knot pusher to secure our repair. We then cut our
strands and we visualize the first anchor repair, nicely reapproximating the labrum
to the face of the glenoid. We then place our second anchor, again with
a metal trocar. We inserted the punch and then we tap the bone. And when we are complete
with our tap, we place and seat our anchor. This time we used a single-loaded anchor,
and we retrieve one suture out our anterior superior cannula. We again use our lasso to
pierce the labrum. We then retrieve this loop again outside the cannula and load our suture
into the loop and shuttle it back through the labrum and back out our anterior cannula. We then again place a sliding knot, cinching
it down with a knot pusher, and we secure the knot with several extra knots. Our grasper
you see is holding the labrum down for tension as we tie our knot, and you can clearly see
the labral bumper is coming up nicely to the rim of the glenoid. We then place our last anchor. We punch one final time for our pilot hole.
Then we tap, and then we see that a final double-loaded anchor. Again to prevent tangling,
we retrieve three of the sutures out our anterior superior portal. We again use our lasso to pierce the labrum
and we retrieve the loop and our suture simultaneously out our anterior superior portal. We shuttle our blue suture through the labrum
and we secure this with a sliding knot in a similar fashion to our other knots, and
cinch this down with extra knots on top and cut our strands when we are complete. We then retrieve our final white suture out
the anterior cannula. One last time, we pierce the labrum with our suture lasso. We again
retrieve our loop and shuttle the suture through the labral tissue. Once the suture is shuttled, we secure this
with one final sliding knot. We again secure this with multiple knots on top, cut our suture,
and once secured, we visualize our repair. We have three anchors, two double loaded and
one single, for a total of five sutures through the labrum. The bumper is recreated and we
have secured our anterior inferior labrum back to its appropriate position on the glenoid. We probe this, and it is sturdy. We next look from above down on the glenoid
from our anterior superior cannula, and we see a solid repair. We have recreated here
the tension in the anterior band of the inferior glenohumeral ligament. You clearly see an intact posterior labrum and now we see a nicely centered humeral head.


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