Arthroscopic Double-Row Anterior Stabilization and Bankart Repair for the “High-Risk” Athlete  Cathal J. Moran, M.D., F.R.C.S.(Orth), Peter D. Fabricant, M.D., M.P.H., Richard Kang, M.D., Frank A. Cordasco, M.D., M.S.  Arthroscopy Techniques  Volume 3, Issue 1, Pages e65-e71 (February 2014) DOI: 10.1016/j.eats.2013.08.011 Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 1 Example of a case suitable for double-row capsulolabral repair. (A) Internally rotated anteroposterior view of a left shoulder showing a large Hill-Sachs lesion with concomitant periosteal elevation along the anterior glenoid neck. (B) Axial proton density magnetic resonance image of a left shoulder showing a large Hill-Sachs lesion along with a large area of anterior capsulolabral avulsion. (C) Axial, sagittal, and 3-dimensionally reconstructed computed tomography scans of a left shoulder showing an osseous Bankart lesion comprising less than 20% of the glenoid articular surface. Arthroscopy Techniques 2014 3, e65-e71DOI: (10.1016/j.eats.2013.08.011) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 2 Setup and examination under anesthesia. (A) The patient is placed in the standard beach-chair (modified Fowler) position using a beanbag extending to the medial border of the scapula for support. (B) After surgical preparation and draping, an examination under anesthesia is performed, including range-of-motion and stability testing (e.g., load-and-shift test). (C) A bump is constructed, placed in the axilla after the initial diagnostic arthroscopy, and in conjunction with the pneumatic arm holder, provides distraction at the glenohumeral joint and enhances the arthroscopic working space. Arthroscopy Techniques 2014 3, e65-e71DOI: (10.1016/j.eats.2013.08.011) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 3 The surface anatomy (clavicle, acromion, and coracoid) and potential portal sites are marked. From medial to lateral, the portal sites are anterior, anterosuperior (rotator interval), anterolateral, and lateral. Arthroscopy Techniques 2014 3, e65-e71DOI: (10.1016/j.eats.2013.08.011) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 4 View of left shoulder through posterior portal in beach-chair position. Elevation of the osseous fragment is performed with the Samurai Blade. In the event that an osseous fragment is identified, the Samurai Blade is used to begin mobilization and develop the plane between the fragment and the remaining glenoid. Arthroscopy Techniques 2014 3, e65-e71DOI: (10.1016/j.eats.2013.08.011) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 5 View of left shoulder through posterior portal in beach-chair position. Anchor placement takes place in 2 stages, after one determines the desired configuration. First, (A) the medial row is placed (2.4-mm BioComposite SutureTak), passed through the capsulolabral fragment by use of a 25° curved SutureLasso, and (B) tensioned through the lateral-row anchors (BioComposite PushLock anchors, 2.9 × 15.5 mm). (C) Final inspection shows an anatomic reconstruction. Arthroscopy Techniques 2014 3, e65-e71DOI: (10.1016/j.eats.2013.08.011) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions

Fig 6 Suture anchor configuration patterns. (A) The Cassiopeia (“W”) divergent technique uses an asymmetric number of anchors (1 more laterally than medially), and the suture limbs diverge from a single point in the capsule to 2 different anchors in the lateral row. (B) The convergent (“M”) technique uses a symmetric number of anchors medially and laterally, and the suture limbs converge to a single medial-row anchor, through 2 different points in the capsule, and converge to a single lateral-row anchor. By use of a 1:1 anchor configuration, suture management and tensioning are more predictable and straightforward. (Reprinted with permission of Primal Pictures Ltd.) Arthroscopy Techniques 2014 3, e65-e71DOI: (10.1016/j.eats.2013.08.011) Copyright © 2014 Arthroscopy Association of North America Terms and Conditions