• Interscalene nerve block followed by general anesthesia

• Arthroscopic tower with 30-degree and 70-degree arthroscope

• Curved suture hook for suture shuttling

• 4.5-mm double-loaded suture anchor

• Arthroscopic cannulas in varying sizes (5.5 mm and 7.0 mm)

• The patient can be positioned in the lateral decubitus position using a beanbag or in the beach-chair position. We prefer the lateral decubitus position.

• Care is taken to pad all bony prominences.

• An axillary roll is placed to minimize the risk of contralateral brachial plexus injury.

• The patient is leaned posteriorly 15 degrees to ensure that the glenoid is parallel to the floor.

• The operative extremity is placed in a balanced suspension system, and depending on patient’s size, 10-15 lb of traction are hung to obtain the desired distraction.

• Adjustments to the suspension system are made to place the arm in 20 degrees of forward flexion and ˜50 degrees of abduction.

• A sterile bump can then be placed in the axilla to improve visualization and access to the axillary recess during the surgery.

• Standard Posterior Portal

• A longitudinal skin incision is made ˜2 cm distal and 1 cm medial to the posterolateral tip of the acromion.

• Care should be taken not to make the portal too lateral, as this may lead to a less than optimal trajectory for viewing or gaining access to the site of avulsion of the inferior glenohumeral ligament (IGHL).

• Standard Anterior Portal

• This portal is created under direct vision through the center of the rotator interval.

• A smooth, 5.5-mm cannula is placed through a small skin incision into the interval.

• For anterior humeral avulsion of the glenohumeral ligament (HAGL) lesions, a second anterior portal (low anterior portal) may be desired for suture management. In this instance, the standard anterior portal should be shifted to the superior aspect of the rotator interval to ensure room for a second cannula.

• Low Anterior Portal (optional)

• While viewing from the posterior portal, a spinal needle is placed between the coracoid and anterior corner of the acromion, ˜1 cm distal to the standard anterior portal.

• The spinal needle should enter the joint through the inferior aspect of the rotator interval.

• Once location is confirmed, a small skin incision is made and a Wissinger rod is placed along the same trajectory as the needle.

• A 5.5-mm cannula is then passed over the rod.

• 7 O’Clock Portal (optional)

• This portal is optional for anterior HAGL lesions; however, it can be used for suture management with these lesions.

• It facilitates visualization as well as instrumentation in reverse HAGL (rHAGL) lesions involving avulsion of the posteroinferior glenohumeral ligament.

• With the arthroscope in the anterior portal, an 18-gauge spinal needle is used to identify optimal portal placement.

• The spinal needle should enter the skin ˜4 cm lateral to the posterolateral tip of the acromion.

▪ Analysis of the needle trajectory is crucial to ensure proper position of the portal.

▪ The needle trajectory should be perpendicular to the floor.

• Once trajectory is confirmed, a small skin incision is made and a Wissinger rod is placed along the same trajectory as the needle into the joint.

• A 7-mm cannula is then passed over the Wissinger rod into the joint.

• While viewing through the posterior portal, the anteroinferior quadrant of the glenohumeral joint is inspected.

• A full assessment of the anteroinferior labrum should be made because labral tears have been found to occur concomitantly in these patients.

• The leading edge of the IGHL can be seen medially, often scarred down to the medial interval tissue.

• The underlying subscapularis muscle fibers are easily visualized, a finding pathognomonic for HAGL lesions.

• At this point, the arthroscope can be switched into the anterior portal to better visualize the IGHL’s footprint on the anterior humeral neck or a 70-degree arthroscope can be used to better visualize the footprint from the posterior viewing portal (Fig. 10-2).