1. Principles and Applied Anatomy for Arthroscopic Anterior and Posterior Instability Surgery of the Shoulder Edward Tillett, M.D. Department of Orthopedic Surgery University of Louisville

2. Anterior and Posterior Instability of the Shoulder The loss of capsulolabral support on the anterior or posterior glenoid The loss of capsulolabral support on the anterior or posterior glenoid

3. Anterior and Posterior Instability

4. Principles of Arthroscopic Anterior and Posterior Instability Repairs Appropriate Portal Placement Mobilize Capsule and Labrum Prepare Bone for Healing Response Appropriate Suture Anchor Placement Suture Passage through Capsule and Labrum Secure Knot Tying Appropriate Fixation of Capsule and Labrum

5. Appropriate Portal Placement Must allow access to the inferior aspect of the anterior and posterior glenoid for capsule and labrum mobilization and suture anchor placement Must allow access to the inferior aspect of the anterior and posterior glenoid for capsule and labrum mobilization and suture anchor placement

6. Anterior Inferior Portal Capsulolabral release Capsulolabral release Bone preparation Bone preparation For low anterior suture anchor placement (5 o’clock position) For low anterior suture anchor placement (5 o’clock position) *This portal is just superior to the subscapularis tendon and should be angled enough for suture anchor placement

7. Appropriate Location of Anterior Inferior Portal

8. Posterior Inferior Portal Capsulolabral Release Capsulolabral Release Bone Preparation Bone Preparation For Low Posterior Suture Anchor Placement (7 o’clock position) For Low Posterior Suture Anchor Placement (7 o’clock position) *This usually is the standard posterior portal which is 2cm inferior and medial to the posterolateral border of the acromium

9. Posterior Inferior Portal 2 MRI********** 2 MRI**********

10. Mobilize Anterior Capsule and Labrum Frequently, the capsule and labrum heals in a medially displaced position on the glenoid Frequently, the capsule and labrum heals in a medially displaced position on the glenoid Therefore, it should be released to the 6 o’clock position to allow it to be advanced to the normal anatomic position Therefore, it should be released to the 6 o’clock position to allow it to be advanced to the normal anatomic position

11. Mobilize Anterior Capsule and Labrum

12. Mobilize Posterior Capsule and Labrum

13. Mobilize Anterior Capsule and Labrum

14. Axillary Nerve Anatomy The axillary nerve may be at risk when manipulating tissue at the inferior aspect of the glenoid rim. The axillary nerve may be at risk when manipulating tissue at the inferior aspect of the glenoid rim. Where is it? Where is it? “Determining the Relationship of the Axillary Nerve to the Shoulder Joint Capsule from an Arthroscopic Perspective” – –By: M.R. Price, MD, MS, Edward D. Tillett, MD, Robert D. Acland, MD, and G. Stephen Nettleton, PhD Journal of Bone and Joint Surgery, October, 2004

15. Axillary Nerve Anatomy The axillary nerve is closest to the glenoid rim at the 6 o’clock position The axillary nerve is closest to the glenoid rim at the 6 o’clock position It lays about 12mm from the inferior glenoid rim and is adjacent to the capsule It lays about 12mm from the inferior glenoid rim and is adjacent to the capsule

16. Axillary Nerve Anatomy

18. Prepare Bone for a Healing Response Bone Should be decorticated on the medial scapular neck just off the glenoid rim Bone Should be decorticated on the medial scapular neck just off the glenoid rim

19. Appropriate Suture Anchor Placement Suture Anchors should be placed up onto the glenoid rim Suture Anchors should be placed up onto the glenoid rim The most inferior suture anchors for anterior and posterior instability should be placed at the 5 or 7 o’clock position The most inferior suture anchors for anterior and posterior instability should be placed at the 5 or 7 o’clock position

20. Anterior Inferior Suture Anchor Placement

21. Posterior Inferior Suture Anchor Placement

22. Appropriate Suture Anchor Placement

23. Suture Passage: Capsule and Labrum Suture is passed through Capsule and Labrum Suture is passed through Capsule and Labrum Will allow an adequate shift of tissue to a normal anatomic position on the glenoid rim Will allow an adequate shift of tissue to a normal anatomic position on the glenoid rim The suture through the capsule and labrum should be placed inferior to the level of the suture anchor The suture through the capsule and labrum should be placed inferior to the level of the suture anchor Suture shuttle using an accessory portal is easiest Suture shuttle using an accessory portal is easiest

24. Anterior Suture Passage Through Capsule and Labrum

25. Posterior Suture Passage Through Capsule and Labrum

26. Suture Passage Through Capsule and Labrum

27. Anterior Superior Portal This portal is at the superior aspect of the rotator interval between the subscapularis and biceps tendons This portal is at the superior aspect of the rotator interval between the subscapularis and biceps tendons Used for the suture shuttle Used for the suture shuttle

28. Anterior Superior Portal

29. Posterior Superior Portal This portal is about 2cm distal and anterior to the posterolateral border of the acromium This portal is about 2cm distal and anterior to the posterolateral border of the acromium

30. Posterior Superior Portal 2 Arthro Pix****** 2 Arthro Pix******

31. Secure Knot Tying Learn how to tie sliding knot and half- hitch knots Learn how to tie sliding knot and half- hitch knots

32. Fixation of Capsule and Labrum *The labrum and capsule are shifted and fixed up on the glenoid rim.

33. Anterior Capsulolabral Repair

34. Posterior Capsulolabral Repair

35. Anterior and Posterior Labral Repairs