Can you hear me? So we're going to go ahead and do a labral repair here. All right, if I can have your attention for a second, Dr. Orwin and I have a specimen here. We'll show a quick labral repair that we're all working on here. So if I can have you take a break there for a second. We'll go ahead and show this real quick, show you some equipment here. So this shoulder, we have it in the lateral cubitus position. This is a right shoulder. I have my scope posteriorly like you've all done so far today. We've already kind of established our portals. We made first our anterior superior portal like you did. And a lot of times you want to put this, when I'm doing an instability case, I'll go posterior to the biceps or right anterior to the anterior edge of the supraspinatus and just posterior to the biceps. This will be our viewing portal. Then we created our working portal. You want it to be lateral, right? So we want to be up along the edge of subscap. So there's the upper border of subscap right there. And we'll put our portal in there and we have good spacing between our cannulas so we can work really well. Dr. Orwin is showing our pathology. So we created this anterior bank heart lesion. And we'll look at that a little bit better. But from posterior here, you can do your exam. You can see biceps. We can see rotator cuff if we need to up into here. So the way I like to do these, I'm going to go ahead and switch the scope now to the anterior superior portal. This is one of the advantages of doing these in the lateral decubitus position is you can get a little bit better exam and a little bit better visualization looking this way. Of course, we're going to have a problem with that. There we go. So let's see. We'll go ahead and put the scope in here. All right. So looking from the front here, we have a little bit of tissue in there. See if we can't get that out of there. All right. So now we're looking from anterior superior here. So this gives you a good global view of the glenoid. So if I get my elevator, black-handled elevator. So if we're working with a case here. No, this is it. If we're working with a case here, so we can now get down right here along the anterior edge and we can kind of work on releasing our labrum here. Now we kind of worked our labrum here. Now we kind of worked on this a bit already, but you can see this is six o'clock right here. So we get pretty good access even without making accessory portals, but we can kind of come down into this area. So you want to make, this is where you spend your time on these cases is making sure you've got a good release there. You can look down here with the scope. If you get it really good, it's a little bit more difficult in the cadavers, but if you release all this inferior tissue, you can see fibers of subscapularis down into that hole there. So, you know, you've released the whole anterior edge there. And then looking from here as well with your instabilities, you want to do an exam as well. So here's anterior inferior glenohumeral ligament. You may make sure you don't have any hagel lesions. You can rotate the head to make sure there's no anterior hagel or the raggle lesion, something in the back, all looks pretty good. And here's our poster labrum as well. So we're going to do a three anchor anterior repair here. We're using the, the my tech anchors here. So we're going to standard type of anchor. These have, these have a pre knotted mechanism on them. So we're going to use our guide. So in the John, let me have you pull out that canola. Great. Thank you. So we're going to put our guide right down where we need to go. And you can see if you've got good exposure, you don't need a curve guide. You don't need anything like that. So we're right down right near, you know, 545 near six o'clock there. So we're going to go ahead and drill our hole. And that's a positive stop. Okay. Then we put the anchor down the cannula, the mallet. You get all the way to the, yep, perfect. And then if you can have you pull this card out and just let it hang, yep, that comes out. Just let it hang. And then rotate this, what lines up, there you go, and then just kind of jiggle it out and out of there. Perfect. All right, so there we have our anchor onto the bone there. And John, hold the candela for me, please. There we go, great. All right, so in this system, I have to know which one is which. So we're going to put a candela posteriorly. So I need a switching stick, and let's put that other yellow candela posteriorly here. We'll need a knife as well. So we'll come into the shoulder here, yeah. Go ahead and create a little larger candela, or a little larger hole here for our candela. Great, thank you. Beautiful. Thanks. We'll go ahead and bring this in the back here to make sure we're not pushing the scope off the... hold the shoulder here, there we go. Great, so we'll put in our posterior canal so I can control some sutures here, so yep you just come out with that and then come out with the, okay. It's hard working with an attending surgeon. So all right, so we've got that all there, so I need the green handle grasper please. So in with this anchor I have to determine green, I have to determine which one is which, so John here's what I'm going to have you do. We're going to hold both of those, I'm going to pull two of them like this and then I want you to pull up on the one with the card, so let go of the other one and just pull on the one with the card. Great, then we'll just bring this out here. All right, then I need the passer, so I'll take my suture passer, so I'm going to use a 45 degree passer on the right, right angled right. Great, thank you. So the key things for this as your instructors have been showing you is advancing the capsule as well as repairing the labrum. So we'll go ahead and come in here, so here's my anchor, so John if I can have you come down and maybe lift up the humeral head a little bit will be great. So Dr. Oren's going to help position, there we go, that's great. So we can, you want to come below your anchor and a little bit lateral and you can come into the capsule, you can pop that in there and then you want to kind of make the turn here with your instrument, you can come right out here so you can advance the tissue as well as fix the labrum and this system will just do that and then I need the blue handle grabber, thank you. So now we can come in here and we can take our passer, all right John if you can load that into there. All right great and then we'll go ahead and pull that back through. All right great, all right and then John if I can have you hold the scope here. So now we're looking at, so we have a nice little advance of the capsule there in the labrum, so in this system this has a pre-tied knot, so we're going to go ahead and use this, this is called a pro knot, different companies have different ways, a lot of them are even knotless, this one still has a knot, it's a little lower profile knot, we'll go ahead and put our knot down and we're going to work on tightening that up a little bit here, so we're going to go ahead and put this suture in my knot pusher, so we'll go ahead and work this down here, see it's a double loaded thing and it's, this is a rack hitch knot that's here and the suture on this is designed to become two sutures, so then you can tie some half hitches around the knot for security. So we just do standard arthroscopic knots, so we'll come down here initially just to kind of tighten that down a bit, so you get a nice tight there, now I'm just going to do a single throw here and bring that down and then I'm going to reverse and flip my post just so I get a good square knot down onto that, great, so there's our first one in there and then the cutter, we'll go ahead and cut that and then we'll do our second one, we'll do our second one, so we get set up for the second anchor, so there's our first anchor down, I'll trade you for John, a little shoulder dance here, all right and then I need, yep the blue, so we'll use the guide again and I want to see this, now we're going to put this just superior to the first one, so let me have you come out with this John, just grab that and sometimes you'll roll up the tissue bits, you want to make sure you're not just moving more and more onto the face of the glenoid, so you want to push this out a little bit, go ahead, we're right again on the edge of the glenoid, you don't want to be up onto the glenoid face too much, you want to be a little bit though to be able to get this drilled in there, to kind of break out a little bit. Okay. Great. Great. You're taking the whole thing. Yep. Great. Go ahead and separate off that again. Yep. Great. All right. Great. All right. So we got our next anchor in. Now I need... the grasper. Yeah, so the anchor came out. So okay, so cadavers. So our anchor came out. So that happens in the OR sometimes. So we need to kind of decide what else we're going to do here. So I want to get a probe and see what our bone looks like there. Yeah, just that's not great. So we're going to try to move to a little different position for sure. So let me see the guide back again. So in this case, I told you not to move up on the face, but we are going to move up onto the face a little bit here. Just to get a little bit better angle here. So let me try that. I'm going to angle in this a little bit. Alright, we'll see if we get a little bit better bite here. Can you go get a third anchor? Alright, so we got our anchor in. Let's see if this one stays. Bones are not looking so great there either. There, better. Alright, green handle grasper. And then John, I'm going to have you pull up on that carded one again so I can tell the difference on these strands here. They've got one marked. I don't know which one's marked. Go ahead and pull. There you go. Great. Alright, good. And then we're going to use our passer back. Yeah, this one. And then I'll need that blue handle grabber. I don't know where you put it. So, you know, you can kind of see a fold right here. So this is where the capsular tissue has been advanced. We're going to grab at that fold again. So we continue to advance the capsule. And then we're going to go ahead and roll up our instrument here again to get capsule and labrum. We'll come right out there. And then is it just missing? I'll take the green. That's fine. So then we'll go ahead and grab our loop here out the back. And John, if you come over here and load that in, it'd be great. Shoulder dance. Alright, there we go. Okay, good. We'll bring this back through and around the labrum and capsule. Maybe hold this just a little stuck there. Alright, great. So now we've got our second stitch in there. So again, advancing capsule while we're moving it. And we'll go ahead and deploy our knot here again. And then we'll just go ahead and cinch that down a bit. We'll use the knot pusher to do that. There it is, I see it. There it is right there. All right, so we're going to go ahead and cinch this knot down a bit. So since this is a rack hitch knot, it really, it doesn't really back up well, but it does get stronger if you put your half hitches behind it. And then what I'll do a lot of times after this, we'll kind of assess this repair as it's going along. And to further tighten up the inferior pouch, we're going to go ahead and put a stitch posteriorly, a capsular plication stitch posteriorly. So for that I'll need the yellow passer. So the advantage of doing these things laterally, thanks John, doing these things laterally is that I can go anterior and posterior without moving anything. So now we're going to address the posterior side here. So we can see, here's our cannula. So we get an idea of a little bit of capsular laxity. So I want to try to tighten up the capsule. I'll take the yellow. So we're going to use the labrum as the anchor on the back here. So I'm going to bring in my passer. And from here, I can grab some capsule here. So we're going to pop in there like that. We're going to advance this as well. We can do what's called a pinch tuck here. So we're going to bring this through here. So we're going to pinch this capsule. And now I'm going to bring it through the labrum. So this is, again, tensioning the pouch by tightening the front, which we did off the anchor. And now off the back with the stitch. So go ahead and grab that. That would be great. Yep, perfect. Pull that through. And then we're just going to put a stitch in this. And we'll do a simple stitch back here. Thank you. Great. Got it. Great. So we're going to pull this back through. We'll bring our stitch back through here. Awesome. Don't take the grass, the green handle. I need that one. Thank you. Yep, perfect. All right, great. And then I need the knot pusher. Any second. So I need to identify my post. So I want the post farthest away. This side needs to be my post so it gets advanced. We'll see how well this labrum holds. I don't know. We'll see. So I'll do a sliding knot here. I like to use an SMC knot. So we're going to do a sliding knot here. So we'll go ahead and get that all organized. Organized. And we'll slide this down. So this is a locking sliding knot. So you don't want to pull on the other limb because it will lock where it sits. So we'll go ahead and bring in our knot pusher. And we'll go ahead and tighten that up there. So this labrum is a little loose. So in a regular patient, you'd probably put an anchor back here as well. But just to show the plication stitch here. And again, we'll back that up with some half hitches. Just to make sure that it's all good there. Alright. Cutter. And then we're going to put in our last anchor up the front. Now, if I were to do a remplissage or something like that, I would have done that first. So we would have our stitches then coming out of the back of the humeral head here. So I would still have those up into here. Because as soon as you start tightening these up, it would be a little bit more difficult and you'd close those at the end. So we're going to do our last anchor up here in the front. Thank you. There you go. We're going to put that right up into here. Hopefully this one holds. Alright, great, so we got our last anchor in, Grasper, and we're going to go ahead and identify our limb, go ahead and pull up on the one with the cardigan, alright, and then we'll take the passer. So you try to make these surgeries as repetitive as possible, so we're going to put in our last anchor here, we're going to pass this suture, so again, here's our capsule that's getting all folded up here, so we're going to again grab this, we continue to advance capsule, like that, and then we're going to come around and come through labrum, like that, there, and we'll go ahead and grab that, get that down, great. There's a lot of different instrumentation out there that works really well, so I encourage you to use different anchors and different techniques on doing this, there's different ways of doing this, so we're going to go ahead and put this last one down here, and we'll take that pre-tied knot, and we just advance that down through the cannula, and we'll go ahead and separate these, so I can get the knot pusher down there, thank you. Alright so we're going to cinch down that knot a bit, and make sure we get all the little kinks out of it there, there we go, yeah, the anchor looks like it might be floating up there a little bit, but I'm going to tie this down for the point here, alright good. Alright so there's a simple anterior labral repair with a posterior capsular placation, so there you are, so I encourage you to work with that in the lab, maybe get that done for you, try some posterior placation stitches in the back, you can do posterior labral repairs as well, so we'll let you get back to work there, thanks for your attention.

labral repair procedure

equipment used

shoulder examination

anterior bankart lesion

three-anchor anterior repair

posterior capsular plication stitch