The Use of Accessory Portals in Bankart Repair With Posterior Extension in the Lateral Decubitus Position  Gregory L. Cvetanovich, M.D., Jason T. Hamamoto, B.S., Kevin J. Campbell, M.D., Mark McCarthy, M.D., John D. Higgins, B.A., Nikhil N. Verma, M.D.  Arthroscopy Techniques  Volume 5, Issue 5, Pages e1121-e1128 (October 2016) DOI: 10.1016/j.eats.2016.06.003 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 The patient is positioned in the lateral decubitus position with the right shoulder prepped and draped. Posterior portals are shown in (A) and anterior portals are shown in (B). Skin markings are shown for the portals: (1) posterior viewing portal, (2) posterior working portal, (3) 7-o'clock portal, (4) anterosuperior viewing portal, (5) anterior working portal, and (6) 5-o'clock portal. Arthroscopy Techniques 2016 5, e1121-e1128DOI: (10.1016/j.eats.2016.06.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Diagnostic arthroscopy is performed with the patient in the lateral decubitus position for the right shoulder. Images from the posterior viewing portal show (A) anterior, (B) inferior, and (C) posterior images demonstrating a Bankart lesion with posterior extension with labral tearing from 2-o'clock to 8-o'clock (blue arrows). Labels in figure: 1, labrum; 2, glenoid; 3, humeral head. Arthroscopy Techniques 2016 5, e1121-e1128DOI: (10.1016/j.eats.2016.06.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Arthroscopic images in the lateral decubitus position viewing from the posterior viewing portal for the right shoulder show (A) establishment of an anterior working portal via needle localization just above the subscapularis. (B) An 8.25-mm cannula is placed and an arthroscopic shaver is used to gently debride frayed labral tissue. (C) The anterosuperior portal is then established via needle localization just posterior to the biceps tendon. Labels in figure: 1, labrum; 2, glenoid; 3, humeral head; 4, subscapularis; 5, long head of biceps tendon. Arthroscopy Techniques 2016 5, e1121-e1128DOI: (10.1016/j.eats.2016.06.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 A Bankart elevator is used from the anterior working portal with an 8.25-mm cannula (A) to elevate the labrum from the glenoid in a single sleeve (B). (C) The glenoid rim is then lightly decorticated with a hooded bone-cutting shaver. The patient is positioned in the lateral decubitus position viewing from the anterosuperior portal for the right shoulder. Labels in figure: 1, labrum; 2, glenoid. Arthroscopy Techniques 2016 5, e1121-e1128DOI: (10.1016/j.eats.2016.06.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 The patient is positioned in the lateral decubitus position viewing from the anterosuperior portal for the right shoulder. (A) The posterior working portal is established via spinal needle localization and an 8.25-mm cannula is placed. (B) The 7-o'clock portal is then established via spinal needle localization. A stab incision is made and the 7-o'clock portal is used for percutaneous anchor placement in the posteroinferior quadrant with drilling (C, D) followed by anchor placement (E, F). Labels in figure: 1, labrum; 2, glenoid. Arthroscopy Techniques 2016 5, e1121-e1128DOI: (10.1016/j.eats.2016.06.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 The patient is positioned in the lateral decubitus position viewing from the anterosuperior portal for the right shoulder. The method of suture passing for posteroinferior labral repair with double-loaded all-suture anchor and with the spectrum device is shown. (A) One suture is retrieved to the anterior working portal. (B) The spectrum to the left is used through the posterior working portal cannula to take a bite of the posteroinferior labrum. (C) The polydioxanone (PDS) suture (Ethicon, Somerville, NJ) is advanced and retrieved from the anterior working portal. (D) The PDS is used to pass the suture through the labrum and back out the posterior working portal. (E) This process is repeated with the other suture from the double-loaded all-suture anchor. (F) The knots are tied with alternating half hitches with the knot pusher through the posterior working portal cannula. (G) Sutures are cut. (H) The other suture is tied and cut in the same fashion and further posterior labral repair is performed in the same fashion. Labels in figure: 1, labrum; 2, glenoid; 3, humeral head. Arthroscopy Techniques 2016 5, e1121-e1128DOI: (10.1016/j.eats.2016.06.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 The patient is positioned in the lateral decubitus position viewing from the anterosuperior portal for the right shoulder. (A) The 5-o'clock portal is established via spinal needle localization. A stab incision is made and the 5-o'clock portal is used for percutaneous anchor placement in the anteroinferior quadrant (B) with drilling (C) followed by anchor placement (D). (D) The completed posteroinferior repair can also be seen as well as a polydioxanone suture (Ethicon) passed through the labrum from the posterior working portal. The spectrum device is used throughout the repair in this manner and suture management is performed in the same fashion throughout to improve efficiency. Labels in figure: 1, labrum; 2, glenoid; 3,humeral head. Arthroscopy Techniques 2016 5, e1121-e1128DOI: (10.1016/j.eats.2016.06.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 The patient is positioned in the lateral decubitus position viewing from the anterosuperior portal for the right shoulder. The initial anteroinferior double-loaded all-suture anchor has been placed via the 5-o'clock portal and a pre-placed polydioxanone (PDS) suture (Ethicon) is in place (A). One suture is retrieved from the anterior working portal and then the pre-placed PDS is used to shuttle the suture out of the posterior working porta. (B) A spectrum is then used to pass the PDS suture through the labrum. (C) The PDS and suture are retrieved from the posterior working portal. The more inferior suture is then tied (D) and cut (E) from the posterior working portal. The more anterior suture is tied (F) and cut (G) from the anterior working portal (H). An analogous process is repeated using single-loaded all-suture anchors to complete the anterior repair. Labels in figure: 1, labrum; 2, glenoid; 3, humeral head. Arthroscopy Techniques 2016 5, e1121-e1128DOI: (10.1016/j.eats.2016.06.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 The completed labral repair is shown. The patient is positioned in the lateral decubitus position viewing from the anterosuperior portal for the right shoulder. Labels in figure: 1, labrum; 2, glenoid. Arthroscopy Techniques 2016 5, e1121-e1128DOI: (10.1016/j.eats.2016.06.003) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions