• 4.0-mm arthroscope and camera

• Two or three 8.25-mm cannulas

• Wissinger rods

• Cannulated tissue dilators

• Arthroscopic shaver with 3.5-mm shaver and 4-mm hooded burr

• Arthroscopic rasps

• Angled tissue elevator

• Mallet

• Percutaneous drill sleeve and targeting spear

• Anchor-specific drill bit and battery-powered drill

• Multiple angled and straight retrograde suture-passing devices

• Suture grasper

• Ringed suture

• Knot pusher

• No. 1 polydioxanone suture

• Implants

• 2.4- and 3-mm double-loaded suture anchors

• 2.9-mm knotless suture anchor

• 1.5-mm high-tensile, nonabsorbable tape

• Physical examination is performed in the preoperative holding area to confirm presence of symptomatic laxity and instability (or apprehension) in multiple planes, as well as tenderness to palpation (eg, long head of the biceps).¹,²,³

• After ultrasound-guided interscalene block and general endotracheal anesthesia are administered, bilateral examination under anesthesia is performed.

• Range of motion.

• Anterior: anterior load shift test.

• Posterior: jerk and Kim test, posterior load shift test.2,3

• Inferior: sulcus sign (in neutral and external rotation), Gagey test.²,³

• The patient is positioned in the lateral decubitus position.

• All bony prominences and at-risk neurovascular structures are padded, including peroneal nerve, radial nerve, and greater trochanter.

• An axillary roll and foam headrest are used, and a deflatable beanbag is positioned near the inferior angle of the scapula.

• A dual traction lateral shoulder positioner is used with a sterile arm sleeve, and 5 lb of lateral distraction and distal traction are applied (Fig. 5-1A).

• A foam roll also can be placed under the axilla for additional distraction.

• The posterior viewing portal is created in line with the posterolateral margin of the acromion and slightly superior to the standard posterior viewing portal.

• The anterior working portal is placed under needle localization (or inside-out technique) above the superior margin of the subscapularis and in line with the anterolateral margin of the acromion.

• The posteroinferior (7 o’clock) portal is placed under needle localization ˜5 cm distal and lateral to the posterior viewing portal.

• The transsubscapularis (5 o’clock) portal is an optional percutaneous portal for anteroinferior anchor placement.

• The anterosuperior portal is an optional viewing portal for posterior and inferior capsular plication.

• After establishing the anterior and posterior portals, a thorough 15-point arthroscopic evaluation is conducted (Video 5-1).

• The long head of the biceps is withdrawn intra-articularly to evaluate for hyperemia, synovitis, or other sources of damage.

• The anteroinferior and posteroinferior labrum are inspected for cracking, attenuation, and consistency (Fig. 5-2A and B).

• Laxity and redundancy of the posterior and anterior bands of the inferior glenohumeral complex and axillary pouch are evaluated.

• Competency and volume of the rotator interval are assessed.

• Dynamic examination of glenohumeral translation also can be done under arthroscopic observation for comparison after capsular plication.