23 Double-Row Labral Repair
Abstract
Double-row labral repair techniques have been developed under the concept that, as with double-row rotator cuff repair, better initial fixation strength and greater bone to tissue contact area are achieved. The technique is especially relevant for select bony Bankart lesions, and potentially for high-risk populations such as patients with recurrent dislocations, poor-quality capsulolabral tissue, young age, high activity level, and other risk factors for recurrence. Recent advances in anchor design, equipment, and surgical technique have allowed arthroscopic double-row labral repair to be performed in a time-efficient manner and with a less steep learning curve. For open stabilization techniques, double-row repair poses minimal extra technical difficulty over single-row repair. Long-term clinical outcome data are sparse; however, the theoretical benefits of double-row labral repair, which are supported by biomechanical research, make it a useful tool for select cases and a technique that warrants continued investigation and refinement.
23.1 Goals of Procedure
The purpose of double-row labral repair is to maximize strength and contact area of the repaired capsulolabral tissue to its footprint on the anteroinferior glenoid. Advances in surgical technique and anchor design have allowed for a more anatomic repair to be achieved in a timely and efficient manner.
23.2 Advantages
Double-row labral repair has been shown in biomechanical studies to improve initial fixation strength 1 and increase the contact area of glenoid bone to capsulolabral tissue. 2 , 3 The technique has also been shown to improve fracture reduction and stability in bony Bankart lesions in a cadaver model. 4
23.3 Indications
For any anterior stabilization procedure that is being performed, there are multiple options for anchor configuration, as well as approach (open vs. arthroscopic). Using a double-row technique or hybrid technique as described in this chapter is a viable option in any Bankart repair, with downsides being potential increases in cost and operative time, which is a similar situation to the debate over performing double-row or single-row rotator cuff repair. Previous studies have focused on using double-row labral repair in patients who have risk factors for recurrence, including bony Bankart lesions, ALPSA (anterior labral periosteal sleeve avulsion) lesions, contact athletes, glenoid bone loss, revision surgery, and recurrent instability. 5 , 6
23.4 Contraindications
In cases where glenoid bone loss is greater than 20 to 25%, a bony reconstruction procedure is recommended. There are no absolute contraindications to using a double-row technique over a single-row technique. Performing a double-row repair after a prior double-row repair may begin to pose problems with anchor placement and fixation depending on the number and size of anchors used. Potential downsides to double-row repair include increased cost, increased operative time, and higher technical difficulty, though the arthroscopic technique described in this chapter with four anchors and four passes with the suture lasso can be done without significant increase in operative time or technical difficulty.
23.5 Preoperative Preparation
Imaging is obtained on an individualized basis, including X-rays, MRI, and sometimes CT scan with 3D reconstructions when evaluating for glenoid bone loss. Assessment for Hill–Sachs lesion, humeral avulsion of glenohumeral ligament (HAGL) lesion, bony Bankart, and glenoid bone loss is taken into consideration when formulating the surgical plan.
23.6 Operative Technique
23.6.1 Arthroscopic Repair Technique
Patient Positioning
After placement under general anesthesia, the patient is positioned in the lateral decubitus or the beach-chair position depending on surgeon preference. In this technique, the beach-chair position is used. An arm-positioning device is used to allow optimal visualization of the glenohumeral joint while freeing up an assistant to help with the procedure. Prior to incision, examination under anesthesia is performed, testing for range of motion, and anterior and posterior instability. External rotation is measured with the arm adducted and compared to the contralateral side.
Portal Placement
A standard posterior portal is established inferior and medial to the posterolateral edge of the acromion, aimed toward the tip of the coracoid process. An anterolateral portal is established using needle localization with an 18-gauge spinal needle in the rotator interval, superior to the long head of the biceps. A 5-mm-diameter smooth cannula is placed here for suture management. Next, an anterior portal is established via needle localization just superior to the subscapularis tendon, taking care to place it medially and inferiorly enough that it allows optimal access to the anteroinferior glenoid rim. An 8.25-mm threaded cannula is placed.
Related posts:
22 Role of Remplissage in Anterior Shoulder Instability
21 Open Anterior Stabilization (Bankart/Capsular Shift)
24 Anterior Humeral Avulsion of the Glenohumeral Ligament Repair
30 Partial Humeral Head Replacement: Allograft and Prosthetic
20 Arthroscopic Anterior Stabilization
34 Modified McLaughlin for Posterior Dislocation
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