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Operative management of symptomatic labral tears of the shoulder has traditionally been the preferred treatment. Arthroscopic techniques and equipment continue to be refined and subsequent new recommendations for treatment are being developed. Contemporary techniques for arthroscopic knotless repair offer possible advantages over traditional arthroscopically tied knots. Although knotless repair of labral tears is well recognized, advancements continue to progress toward stronger fixation with reduced risks of cutting through the labrum and chondral abrasion. The suture tape used in the technique presented for arthroscopic knotless repair is stronger and flatter than traditional rounded suture and offers many potential benefits.
Treatment of posterior labral tears is often overlooked because of the high prevalence of traumatic anterior instability and emphasis on its management. Advances in arthroscopy have made the diagnosis and management of posterior instability a more frequent topic for discussion. With increased awareness comes an evolution in repair techniques. Compared with the traditional open posterior approach, these methods offer a less invasive, more anatomic approach to repair with fewer potential complications. Knotless techniques have further propelled the evolution in treatment and offer the option of a small bioabsorbable implant with flat, braided, and high-strength polyethylene tape to diminish the concern for knot migration1 and abrasive chondral injury. Knotless techniques also offer potential earlier rehabilitation with a wider footprint of labral compression and secure anatomic fixation without concerns of shearing through labral tissue with early motion. We present our preferred technique for knotless posterior labral repair.
Our technique uses the traditional lateral decubitus position with a bolster under the arm for optimal visualization (Video 1). We strongly advocate the lateral decubitus position for visualization and management of posterior inferior labral tears. A posterior portal is created slightly lateral to the traditional posterior portal site and a diagnostic arthroscopy of the glenohumeral joint is performed. Placement of the posterior portal in a more lateral position facilitates both suture passage and anchor placement without the need for an additional posterior portal. Concomitant pathology may be addressed at the same setting.
Once the posterior labral tear has been evaluated through the posterior portal, an 18-gauge spinal needle is used to localize an anterior-superior portal within the rotator interval that is employed for visualization during the most of the case (Fig 1). A probe is used to determine the extent of the posterior labral tear (Fig 2). The glenoid rim is prepared for labral repair with the use of a shaver (Arthrex, Naples, FL) or burr to lightly decorticate the surface to a bleeding bed (Fig 3). The arthroscope (Arthrex) and working portal may be interchanged to prepare the entirety of the posterior glenoid rim. We recommend using a SLAP burr (Arthrex) or retractor probe through an accessory percutaneous posterior-superior portal to protect the labrum from iatrogenic injury during this process.
After bone bed preparation, an 8-mm clear cannula (Smith & Nephew, Andover, MA) is inserted through the posterior portal for ease of suture passing. A crescent-shaped suture passer (Linvatec, Largo, FL) is initially used to pass a polydioxanone suture (Ethicon, Somerville, NJ) under the labrum (Fig 4). A standard suture-shuttling technique is used to shuttle a 1.5-mm flat, braided, and high-strength polyethylene LabralTape suture (Arthrex) under the labrum in preparation for repair (Figs 5 and and6).6). Because of the thickness of the LabralTape and the acute angle of shuttling, we frequently use a ring grasper as a pulley to prevent abrasion of the labrum during this process. The offset drill guide (Arthrex) is placed just onto the glenoid articular surface to avoid lateralizing the labral tissue. The hard bone drill (Arthrex) is then used to drill a standard hole for a short 2.9 mm × 12.5 mm BioComposite PushLock anchor (Arthrex) (Fig 5). The previously shuttled LabralTape is then threaded through the islet of the anchor and the islet is inserted into the previously drilled hole to confirm the same trajectory (Fig 7). Great care is taken to leave enough slack in the tape before anchor insertion to avoid overtightening or strangulation of the labrum during insertion of the anchor. The anchor is then malleted over the islet to secure the LabralTape over the labrum using press-fit fixation (Fig 8). Once the anchor has been inserted into the bone, additional adjustments in the tension of the tape may not be applied. The free ends of the LabralTape are cut flush with the chondrolabral surface using a Mini Suture Cutter (Arthrex) to avoid any likelihood of chondral abrasion or suture irritation. The process is then repeated working from an inferior to superior direction on the glenoid. Curved suture passers are often necessary as the distance increases from the posterior cannula to the intended passing region of the labrum. Our preference is to place an anchor approximately every centimeter of torn labrum for optimal stability (Fig 9, Fig 10). A probe is used to verify secure repair of the posterior labrum. After repair, the capsule of the posterior portal is traditionally closed using a polydioxanone suture to avoid a potential stress riser.
The advantages of knotless suture anchor techniques have been examined and the outcomes have been favorable in numerous studies. Uggen et al.2 reported equivalent results when comparing glenohumeral motion and load with failure for type II SLAP lesions using knotless and simple suture repair techniques. The rising concern regarding arthroscopic knot migration and subsequent chondral abrasion from high molecular weight suture knots has compelled surgeons to advance labral restoration without iatrogenic injury. Kim et al.1 showed that migration of arthroscopic knots toward the articular surface after shoulder motion does indeed occur. The ability to minimize this risk with a broader, softer, and knotless construct is certainly appealing. Re-establishing the labral height during repair has also been a concern with knotless approaches. Slabaugh et al.3 confirmed that there was no difference between a knotted and a knotless suture anchor construct when re-establishing labral height. Although the most of knotless techniques have been viewed favorably, Sileo et al.4 reported a higher failure rate in knotless repairs of type II SLAP tears using traditional suture in the cadaveric model. They noted that the most common mode of failure was at the suture-soft tissue interface.
Although failure of the suture-soft tissue interface is a common mode of failure with both knotted and knotless repair constructs, LabralTape (Arthrex) offers many potential advantages over the traditional approach (Table 1). Given that LabralTape is wider than traditional suture, the potential for greater surface area compression forces as well as less potential for suture “cut through” is beneficial. Cadaveric data5 support the benefit of a broader surface area for repair, with LabralTape found to be 37% more resistant to tearing through soft tissue compared with #2 FiberWire. This technique would also potentially offer a subsequent stronger repair construct along with higher healing rates and less risk of failure.
Treatment of posterior labral pathology continues to progress with the advent of enhanced resources and technical innovation. Tennent et al.6 originally described an admirable video technique for posterior stabilization using a knotless technique with a traditional suture construct. Our method shows an evolution of preceding techniques with potentially greater labral compression, higher labral “cut through” resistance, fewer chondral abrasive characteristics, lower failure risk, and superior clinical benefits.
Arthroscopic knotless techniques for treating labral tears of the shoulder have experienced a continual evolution. Like any innovation in field of arthroscopy, acceptance takes time and attestation before becoming the gold standard for operative management. Although explicit clinical studies are lacking to validate treatment of posterior labral tears with suture tape, we believe that advances in operative intervention will include these methods because of the potential benefits proposed. The advantages of knotless suture anchors combined with the ability to provide greater compression area of the labrum while reducing the risk of failure and chondral abrasion is an extremely attractive option for management of symptomatic labral tears.
The authors report the following potential conflict of interest or source of funding: M.S.D., P.E.C., and S.E.P. receive support from Arthrex, Bon Secours, DJO, DePuy-Mitek, and Smith & Nephew.
An arthroscopic knotless repair of the posterior labrum using LabralTape in a right shoulder in the lateral decubitus position viewing primarily through an anterior-superior portal.