Suture Anchor Fixation for Anterior Shoulder Instability

• This chapter describes the use of suture anchors in the glenohumeral joint for labral repair and stabilizing operations, both open and arthroscopic. The techniques of anterior and posterior stabilization, including anchor insertion, are described in detail. The use of suture anchors has become the standard for soft tissue repairs in the shoulder.

Important Points

• Suture anchors and their proper insertion are paramount to performing most types of instability surgery.

• The shoulder surgeon must be familiar with their use, insertion, and complications.

• Disastrous complications can result from improper use of suture anchors.

Clinical and Surgical Pearls

• The steps in the technique of labral repair and capsular plication require careful planning, a stepwise process, and suture limb management.

• Knowledge of arthroscopic knot tying is a prerequisite for most suture anchors, although knotless anchors are available that obviate the need for arthroscopic knots.

Clinical and Surgical Pitfalls

• Appropriate diagnosis, patient positioning, and surgical technique are paramount to success in arthroscopic or open shoulder surgery.

Recurrent anterior glenohumeral instability is a common sequela of a traumatic glenohumeral dislocation or recurrent subluxation episodes. The major pathoanatomic features of a traumatic dislocation are the capsulolabral avulsion of the inferior glenohumeral ligament (Bankart-Perthes lesion) and capsular redundancy, which typically worsens with repeated injuries.1–5 Once recurrent instability affects activities of daily living or precludes return to sports, operative stabilization is recommended. Although there is still considerable debate about whether to proceed with surgery after the first traumatic dislocation, the orthopedic literature supports early acute arthroscopic stabilization after a traumatic dislocation in a select group of young athletes who are at high risk for repeated shoulder injuries.^6–11 However, patient issues such as player position, time remaining in a season, and time available for rehabilitation may affect the decision of when to undergo surgery. Immediate stabilization is recommended in athletes who participate in activities or sports in which a subsequent dislocation could be life-threatening (e.g., parachuting or rock climbing).

Before the introduction of arthroscopic techniques in the mid-1980s, shoulder stabilization surgery required a formal deltopectoral approach, through which the subscapularis was either released from its humeral insertion or split longitudinally for access to the glenohumeral joint. The initial technique to reattach the avulsed labrum to bone was done through bone tunnels; however, after their introduction in the 1980s, suture anchors quickly became the most commonly used soft tissue repair devices. With the advancement of arthroscopic shoulder techniques in the 1990s, the number as well as the variety of fixation devices increased dramatically. The introduction of bioabsorbable and then reinforced plastic (PEEK) suture anchors allowed for postoperative imaging without interference from metallic anchors. In addition, revisions, when necessary, were not hindered by retained metallic implants.

Arthroscopic shoulder stabilization offers a number of advantages over traditional open repairs. These include smaller incisions, less muscle dissection, less postoperative pain, and better visualization of the entire glenohumeral joint.¹² The first arthroscopic Bankart repairs were performed by transglenoid suture fixation. Sutures were passed across the glenoid and tied over the posterior fascia. As bioabsorbable polymers were introduced for use in the shoulder, soft tissue fixation with tacks became popular. The tacks were inserted arthroscopically over a guidewire to ensure correct placement. Tacks have been shown to have limited pull-out strength and have, for the most part, been abandoned for shoulder stabilization. The success of metallic suture anchors in open shoulder surgery led to the development of arthroscopic deployment techniques. Development of longer-lasting polymers and high-strength suture made bioabsorbable anchors the most popular choice for soft tissue repair. The goals of any suture anchor are to repair soft tissue to bone and to be able to withstand the forces required for rehabilitation until the normal bone-tissue interface is restored. The focus of this chapter is on the technique of arthroscopic anterior shoulder stabilization with use of suture anchors.