Outcome After Arthroscopic Reconstruction of the

Coracoclavicular Ligaments Using a Double-Bundle

Coracoid Cerclage Technique
Nata Parnes, M.D., Darren Friedman, M.D., Cameron Phillips, M.D., and Paul Carey, M.D.

Purpose: We report the outcome of an arthroscopic technique for coracoclavicular ligament reconstruction using an
anatomic coracoid cerclage. Methods: Between March 2011 and September 2012, 12 consecutive patients with symptomatic chronic (>4 weeks from injury) type V acromioclavicular separation for which nonoperative treatment failed
were treated with arthroscopic double-bundle reconstruction of the coracoclavicular ligaments using tendon allograft by
the rst author. The clinical records, operative reports, and preoperative and follow-up radiographs were reviewed. The
visual analog scale score, Subjective Shoulder Value, Simple Shoulder Test score, and Constant-Murley score were
evaluated preoperatively and at each follow-up appointment. Results: The study included 12 shoulders in 12 young
active-duty soldiers with symptomatic high-grade acromioclavicular separation who were treated with a technique for
arthroscopic reconstruction of the coracoclavicular ligaments. The mean age was 25 years (range, 20 to 35 years). The
injury occurred during sports activity in 11 patients. One patient was injured in a motorcycle accident. The mean time
from injury to surgery was 17.8 months (range, 1.5 to 72 months). The minimum length of follow-up was 24 months
(mean, 30.4 months; range, 24 to 42 months). The mean preoperative and postoperative outcome scores were signicantly different (P < .0001) for all subjective outcome measures. The mean Constant-Murley score improved from 58.4
(range, 51 to 76) to 96 (range, 88 to 100). The mean visual analog scale score improved from 8.1 (range, 7 to 10) to 0.58
(range, 0 to 2). The mean Subjective Shoulder Value improved from 32.9% (range, 10% to 70%) to 95% (range, 80% to
100%). The mean Simple Shoulder Test score improved from 6 (range, 5 to 8) to 11.83 (range, 11 to 12). All patients
returned to their normal preinjury level of activity by 6 months. Radiographs at last follow-up showed no loss of reduction
with maintenance of the coracoclavicular interval. There was 1 complication (8.5%), a postoperative supercial wound
infection, that was treated accordingly. Conclusions: We present an arthroscopic technique for double-bundle tendon
graft reconstruction of the coracoclavicular ligaments using the coracoid cerclage technique. This method showed good
outcomes and maintenance of radiographic reduction with high patient satisfaction and a low complication rate. Level of
Evidence: Level IV, therapeutic case series.

cromioclavicular (AC) joint separation is one of

the most common shoulder injuries in high-level
athletes.1 Rockwood et al.2 classied these injuries according to the magnitude of injury to the stabilizing

From Tri County Orthopedics (N.P.), Carthage, New York; Weill Cornell
Medical College (D.F.), New York; New York Presbyterian Lower Manhattan
(C.P.), New York; Kingsbrook Jewish Medical Center (C.P.), New York; and
Department of Orthopaedic Surgery, Guthrie Army Health Clinic (P.C.), Fort
Drum, New York, U.S.A.
The authors report the following potential conict of interest or source of
funding: D.F. receives support from Arthrex and Allen Medical.
Received October 17, 2014; accepted March 19, 2015.
Address correspondence to Paul Carey, M.D., Department of Orthopaedic
Surgery, Guthrie Army Health Clinic, 11050 Mt Belvedere Rd, Fort Drum,
NY 13602-5004, U.S.A. E-mail: paul.a.carey6.mil@mail.mil
2015 by the Arthroscopy Association of North America
0749-8063/14872/$36.00
http://dx.doi.org/10.1016/j.arthro.2015.03.037

ligaments. Low-grade injuries, types I and II, represent

injury to the AC ligaments without coracoclavicular (CC)
ligament injury. Typically, these are treated conservatively
and most patients return to preinjury status.
High-grade injuries, types IV through VI, result from
injury to the CC and AC ligaments and typically
require surgical reconstruction.3 The optimal treatment for type III injuries is still controversial. Many
different surgical techniques have been reported to
reconstruct high-grade AC joint separation including
screws; plates; muscle transfer; ligamentoplasty procedures; and ligament reconstruction using autograft,
allograft, or synthetic materials.1,4
Carono and Mazzocca4 noted that the greatest challenge of AC reconstruction has been postoperative loss of
reduction. Synthetic materials are mostly effective in early
reconstructions, during the rst 4 weeks. In delayed and
late reconstructions, multiple studies have shown that

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol

-,

No

(Month), 2015: pp 1-8

N. PARNES ET AL.

Methods

Fig 1. The patient is placed in the beach-chair position. The

anatomic landmarks and portal positions are marked: anterior
lateral portal (ALP), anterior portal (AP), supracoracoid portal
(SCP), and coracoid tip (asterisk). The SCP is located between
the coracoid and the clavicle on the palpable medial border of
the coracoid. This is always made using the outside-in technique. All gures show the same left shoulder.

anatomic reconstruction using a tendon graft is superior in

stability, load to failure, and reproduction of the native CC
ligaments function.5-7
Anatomic reconstruction using tendon graft has been
described by use of open and arthroscopic techniques. In
the open approach, adequate access to the coracoid process
for graft xation requires deltoid detachment from the
clavicle, as well as extensive soft-tissue dissection, and
places the neurovascular structures at risk because of suboptimal visibility during graft transfer around the coracoid.
An arthroscopic technique may offer greater visibility in the
relatively small safe zones around the coracoid with less
dissection of the deltotrapezial fascia.3 However, to our
knowledge, all but one of the described arthroscopic
techniques require the use of bony tunnels in the coracoid,
increasing the risk of coracoid fracture and graft xation
failure while reconstructing only 1 of the 2 CC ligaments.8
We report the outcome of an arthroscopic technique for
CC ligament reconstruction using an anatomic coracoid
cerclage. This technique is an arthroscopic modication of
the open anatomic reconstruction previously described by
Carono and Mazzocca.4 We hypothesize that this technique will provide good clinical and radiologic results with
high patient satisfaction and a low complication rate.

Between March 2011 and September 2012, 12

consecutive patients with symptomatic chronic (>4
weeks from injury) type V AC separation for which
nonoperative treatment failed were treated with arthroscopic double-bundle reconstruction of the CC ligaments
using tendon allograft by the rst author (N.P.). The
clinical records, operative reports, and preoperative and
follow-up radiographs were reviewed.
The inclusion criteria were (1) preoperative radiologic
conrmation of grade V AC joint separation, (2) more
than 4-week interval from initial trauma to surgery,
and (3) severe pain localized to the AC joint or loss of
function. Only patients with previous shoulder injuries
or operations were excluded.
Patients were evaluated preoperatively and at each
follow-up appointment with the visual analog scale score,
Subjective Shoulder Value, Simple Shoulder Test score,
and Constant-Murley score. Final follow-up ranged from
24 to 42 months (mean, 30.4 months).
The coracoclavicular distance (CCD) was measured as
the distance from the most superior aspect of the coracoid
base to the undersurface of the clavicle on Zanca-view
radiographs. Because the native relation of the coracoid
and distal clavicle may vary between patients, the difference in CCD between the operative and nonoperative
shoulders was used to assess the reduction.
Surgical Technique
The patient is placed in the beach-chair position using
an articulated arm positioner (Fig 1). A 30 arthroscope
is inserted into the glenohumeral joint through a posterior portal. An anterior rotator interval portal is
established with an outside-in technique using a spinal
needle to verify the position. The needle is replaced
with an 8.25-mm arthroscopic cannula.

Fig 2. The surgeon places an 8.25-mm arthroscopic cannula

through the supracoracoid portal (SCP) while viewing from the
posterior portal using a 70 arthroscope. (AP, anterior portal; C,
coracoid bone; CAL, coracoacromial ligament; L, left.)

CORACOID CERCLAGE CC RECONSTRUCTION

Fig 3. The surgeon uses a 45 suture-shuttling device through

the supracoracoid portal to shuttle a suture loop below the
coracoid (C) while viewing through the posterior portal using
a 70 arthroscope. The asterisk marks the edge of the sutureshuttling device. (L, left.)

A complete diagnostic arthroscopy of the glenohumeral

joint is performed. Associated intra-articular pathology is
documented and addressed as indicated. A motorized
shaver blade is introduced through the anterior cannula
and used to debride the rotator interval until the base of
the coracoid can be visualized. A 70 arthroscope is used
to visualize and expose the coracoid base. For a direct
trajectory toward the coracoid base, an anterolateral
portal is established using a spinal needle in line with the
subscapularis tendon. The needle is replaced with an
8.25-mm arthroscopic cannula. Through this portal, a
motorized shaver blade and radiofrequency device are
used to fully expose the inferior base of the coracoid
process.

Fig 4. The wires and sutures are in position for graft shuttling.
The numbers in red correspond to the sequence of graft
transfers show in Figure 5. (AP, anterior portal; CS, conoid
tunnel; LP, anterolateral portal; SCP, supracoracoid portal; TS,
trapezoid tunnel.)

Fig 5. Graft transfer sequence for coracoid cerclage technique. In step 1, the leading-end graft sutures are pulled
through the conoid clavicle tunnel (C), exiting the anterior
portal (AP). In step 2, by use of the suture loop, which was
previously placed under the coracoid, the leading end of the
graft is then shuttled from lateral to medial below the coracoid, exiting the supracoracoid portal (SCP). In step 3, the
graft is shuttled through the supracoracoid portal, exiting the
trapezoid clavicle tunnel (T), creating a crossing pattern.

At this point, the supracoracoid (anteromedial) portal is

established using a spinal needle with an outside-in
technique. The portal is placed in line with the medial
border of the coracoid, midway between the coracoid and
the clavicle along the medial border of the coracoacromial
ligament. An 8.25-mm arthroscopic cannula is placed
through this portal (Fig 2). A 45 suture-shuttling device
is used through the supracoracoid portal and placed down

Fig 6. The graft is shuttled around the coracoid and through

the clavicle tunnels in a crossing pattern. (C, coracoid; Co,
conoid; L, left; T, trapezoid.)

N. PARNES ET AL.

Fig 7. Completed reconstruction. (C, conoid; CB, coracoid

base; T, trapezoid.)

the medial border of the coracoid until identied about

the coracoid base. The shuttle suture is retrieved through
the anterior portal to shuttle a suture loop below the
coracoid (Fig 3).
A 2-cm incision is made perpendicular to the clavicular
axis, 3.5 cm medial to the AC joint. The deltotrapezial
fascia is released off the clavicle to obtain access to the
superior cortex. Up to 10 mm of the distal clavicle may be
removed using an arthroscopic or open technique only if
there is evidence of AC joint arthrosis or hyperostosis on
preoperative radiographs.
The arthroscope is placed through the anterolateral
portal to improve visualization of the coracoid base. The
target end of the drill guide for the clavicle bone tunnels
is placed through the anterior portal just lateral to the
base of the coracoid. The drill sleeve of the guide is
positioned over the posterior third of the clavicle,
approximately 4.5 cm medial to the distal clavicle edge.
A guide pin is used for placement of the conoid
tunnel. Once the guide pin is inserted in the direction of
the eventual bone tunnel and its tip is visualized at the
desired position, a 5.5-mm cannulated headed reamer
is used over the guide pin to fashion the bone tunnel.
The guide pin is removed, and the nonlooped end of a
exible nitinol passing wire is delivered through the
cannulated reamer and retrieved through the anterior
portal before removal of the reamer.
The target end of the drill guide is then placed
through the supracoracoid portal or anterior portal just
superior to the coracoid. The drill sleeve of the guide is
positioned over the middle third of the clavicle,
approximately 2.5 cm medial to the distal clavicle edge.
A guide pin is used for placement of the trapezoid
tunnel. Once the guide pin is inserted in the direction of
the eventual bone tunnel and its tip is visualized at
the desired position, the 5.5-mm cannulated headed
reamer is used over the guide pin to fashion the bone
tunnel. The guide pin is removed, and a exible nitinol
passing wire is delivered through the reamer and
retrieved through the supracoracoid portal before
removal of the cannulated reamer. Figures 4 and 5

show the technique for passing wires and sutures

before graft passage.
A soft-tissue autograft or allograft (commonly nonirradiated semitendinosus) is prepared on the back table.
Several running locked sutures are placed in the leading
free end of the graft. The graft length should be a
minimum of 10 cm, and the graft should pass through a
5.5-mm sizing block.
The leading-end graft sutures are loaded on the
exible loop on the previously placed passing wire. The
graft is rst pulled through the conoid clavicle tunnel,
exiting the anterior portal. By use of the suture loop
that was previously placed under the coracoid, the
leading end of the graft is then shuttled from lateral to
medial below the coracoid, exiting the supracoracoid
portal. The graft is then shuttled through the supracoracoid portal, exiting the trapezoid clavicle tunnel,
creating a crossing pattern (Fig 6).
Simultaneous superior displacement of the scapulohumeral complex and inferior displacement of the
clavicle reduce the AC joint. At this point, both graft ends
are advanced superiorly through the tunnels, conrming
maximal tightness. Once reduction is conrmed with an
intraoperative Zanca-view radiograph, a 5.5-mm  8-mm
PEEK (polyether ether ketone) tenodesis screw is placed in
the conoid bone tunnel. After verication that initial screw
xation has been successful, a second PEEK tenodesis
screw is placed in the trapezoid bone tunnel (alternatively,
a square knot tied with both free graft ends can be used).
The remaining portions of the tendon graft are then sewn
to each other using No. 2 nonabsorbable braided suture.
The graft ends are placed laterally and secured with No. 2
nonabsorbable braided suture to the AC joint capsule. The
arthroscopic portals are closed with interrupted subcutaneous monolament sutures while the clavicular wound
is closed in layers. Figure 7 shows a typical completed
reconstruction with the anatomic tunnel location referenced from the distal end of the clavicle. Figure 8 shows
preoperative, immediate postoperative, and 2-year postoperative radiographs of a reconstructed chronic type V
AC joint separation. Figure 5 is a schematic representation
of the sequence used for graft passage in the technique.
Postoperatively, the patients are placed in a gunslinger brace for 6 weeks. The patients are allowed
elbow range of motion in the supine position. Active
and passive motion is allowed after 6 weeks. From 6 to
12 weeks, rehabilitation is focused on gradual regaining
of normal shoulder mechanics and range of motion.
Resistance exercises are allowed after 12 weeks. Contact athletics are allowed after 6 months.

Results
The study included 12 shoulders in 12 active-duty
male patients, with a mean age of 25 years (range, 20
to 35 years). The minimum length of follow-up was 24
months (mean, 30.4 months; range, 24 to 42 months).

CORACOID CERCLAGE CC RECONSTRUCTION

Fig 8. (A) Preoperative radiograph showing chronic grade V acromioclavicular joint separation. (CCD, coracoclavicular distance.) (B) The immediate postoperative radiograph shows reduction. (C) The follow-up radiograph at 2 years shows no loss of
reduction.

All the included patients were available for clinical and

radiologic assessment.
The injury occurred during sports activity in 11 patients (3 during football, 3 during wrestling, 3 during
snowboarding, and 2 from a fall on the shoulder while
running). One patient was injured in a motorcycle accident. The mean time from injury to surgery was 17.8
months (range, 1.5 to 72 months). The right shoulder
was involved in 4 patients and the left shoulder in 8,
and the dominant extremity was involved in 7 patients.
All patients had returned to their preinjury job activity in the army and recreational sports by 6 months
after surgery. We found no signicant clinical or
radiologic loss of reduction and there was no need for
revision surgery in any patient.
The mean preoperative and postoperative outcome
scores were signicantly different (P < .0001) for all subjective outcome measures: The mean visual analog scale
score improved from 8.1  1.3 (range, 7 to 10) to 0.58 
0.79 (range, 0 to 2), the mean Subjective Shoulder Value
improved from 32.9%  17.9% (range, 10% to 70%) to
95%  6.56% (range, 80% to 100%), the mean Simple
Shoulder Test score improved from 6  0.95 (range, 5 to 8)
to 11.83  0.39 (range, 11 to 12), and the mean ConstantMurley score improved from 58.4  7.25 (range, 51 to 76)
to 96  4.53 (range, 88 to 100) (Table 1).
At nal follow-up, the mean difference in CCD was
1.02 mm (range, 0 to 3 mm). There was no signicant
loss of reduction and no evidence of clavicle or coracoid

bone fracture. In 1 patient who had a 3-mm loss of

reduction, the trapezoid bone canal was also slightly
widened, raising suspicion that the tenodesis screw may
have loosened. On review of the radiograph, our
impression was that the canal was placed lateral to the
anatomic position in the clavicle. At nal follow-up, 28
months postoperatively, the patient stated that he had
no pain and had returned to military duty and his
preinjury activity level of recreational sports participation. He was satised with the cosmetic result.
In our group of 12 patients, there has been 1 complication (8.5%). A postoperative supercial wound infection
developed in 1 case at the supraclavicular incision site. The
causative organism was identied as methicillin-sensitive
Staphylococcus aureus. The patient was treated with serial
wound irrigations followed by delayed closure. His
allograft-tenodesis screw construct was left intact. He
received intravenous clindamycin and ciprooxacin
treatment for 6 weeks as recommended by an infectious
disease specialist. Six months after surgery, the patient was
asymptomatic and the reconstruction remained clinically
and radiologically stable. The patient returned to recreational sports and full-time military duty and remained in
the same condition at his last follow-up visit 3.5 years after
surgery.

Discussion
This study describes arthroscopic anatomic reconstruction of the CC ligaments using the supracoracoid

Postoperative
12
12
12
12
11
12
12
12
11
12
12
12
11.83
Preoperative
5
6
6
6
5
5
5
8
7
6
7
6
6
Postoperative
0
0
0
0
2
1
0
0
2
1
1
0
0.58
Preoperative
8
8
6
6
10
9
9
7
8
8
8
10
8.1
25
24
27
35
27
22
26
24
22
20
24
21
Mean, 24.75

Age, yr

CCD, coracoclavicular distance; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; VAS, visual analog scale.
*Differences are statistically signicant (P < .0001).

Postoperative
100
100
95
100
88
94
100
100
93
90
92
100
96
Preoperative
51
58
52
56
55
55
52
76
60
63
67
56
58.41
Preoperative
10%
50%
30%
40%
30%
20%
10%
50%
25%
40%
70%
20%
32.9%

Postoperative
90%
100%
100%
100%
80%
95%
100%
100%
90%
90%
90%
100%
95%

SSV

VAS Score

Follow-up,
mo
42
36
35
31
31
29
29
28
27
26
24
24
30.4
Time to
Surgery
6 wk
6 mo
6 mo
2 mo
6 mo
18 mo
3 mo
18 mo
72 mo
30 mo
48 mo
3 mo
17.8 mo

Table 1. Demographic Data of Patients Treated With Arthroscopic Double-Bundle Repair

Constant Score

SST Score

Mean Difference in CCD

Postoperatively, mm
2
1.2
1
0
1
0
1
3
0.5
1
0.5
1
1.01

N. PARNES ET AL.

portal. This technique was developed to avoid some of

the complications reported with current arthroscopic
techniques. The clinical and radiologic outcomes in this
study are comparable with the outcomes of open
anatomic CC ligament reconstruction reported by Carono and Mazzocca.4
AC joint separation is a common injury among young
athletes and motorcycle riders.9 With 1 exception, all of
the patients included in our study were young military
men in their 20s. Eleven of the patients were injured
during sports activity and one in a motorcycle accident.
Young active patients who sustain a high-grade AC joint
separation have better outcomes regarding function and
pain relief with surgical treatment than patients who are
treated conservatively.10,11
Anatomic reconstructions of the CC ligaments using
free tendon grafts have shown greater stability and load
to failure than nonanatomic ligamentoplasty procedures
such as the traditional Weaver-Dunn procedure and
nonanatomic allograft, anatomic suture, and GraftRope
techniques (Arthrex, Naples, FL).7 They also more closely
reproduce the function of the native CC ligaments. In a
recent systematic review, Beitzel et al.12 found a lack of
evidence in the literature to support a single technique as
the gold standard for CC reconstruction. However, on
the basis of their research, they favor techniques that
respect the bony anatomy and restore the native function
of both the conoid and trapezoid.12 Our study reinforces
the ndings of other clinical reports that also support such
anatomic reconstructions.13-16
Carono and Mazzocca,4 in a case series of 17 patients
who underwent anatomic open CC ligament reconstruction with free tendon graft, reported signicant
improvement in pain levels and function. The mean
American Shoulder and Elbow Surgeons score
increased from 52 preoperatively to 92. The ConstantMurley score rose from 66.6 to 94.7. There were 3
failures in this series, and 2 required revision surgery.
The open anatomic CC ligament reconstruction technique described by Carono and Mazzocca4 has several
risks and disadvantages, including extensive soft-tissue
dissection and detachment of the deltoid from the clavicle for graft transfer around the coracoid base. In addition, suboptimal visibility around the coracoid process
during the graft transfer, especially in muscular patients,
may place the neurovascular structures at risk.3
To overcome the aforementioned challenges, several
arthroscopic techniques have been developed and are
widely used today. These techniques permit greater visibility of the base of the coracoid with less soft-tissue
dissection.3 However, to our knowledge, all but one of
the published arthroscopic reconstruction techniques use a
single clavicular tunnel and require drilling of the coracoid
base for graft xation.8 This creates the risk of coracoid
fracture because the high load to failure of the graft or
xation device may exceed the load to failure of the

CORACOID CERCLAGE CC RECONSTRUCTION

cortical bone before device breakage. Milewski et al.17

reported an 80% complication rate in the coracoidtunnel group of 10 patients, including coracoid fractures
in 20% and intraoperative failure of the coracoid button
xation in 10%. In comparison, there was a 35% total
complication rate in the coracoid-loop group. In their
group of 106 patients who underwent open anatomic CC
reconstruction by the coracoid cerclage technique, Carono and Mazzocca4 did not report any coracoid fractures.
Coale et al.18 found in their study that transclaviculartranscoracoid reconstructive techniques cannot restore
the footprint of the conoid and trapezoid ligaments
without signicant risk of cortical breach and fracture.
Cook et al.19 reported an 80% early failure rate in 10
active-duty patients who underwent CC ligament reconstruction with the GraftRope technique. Four patients
required revision surgery.
VanSice and Savoie8 presented the ndings in 12
patients who were treated with arthroscopic AC joint
reconstruction with transfer of the graft around rather
than through the coracoid. In 2 patients inammation
developed from the nonabsorbable suture placed above
the clavicle, which required removal in the clinic. One
patient had a 5-mm loss of reduction, and one patient
required revision because of a fall in the postoperative
period. At 2 to 4 years of follow-up, loss of reduction or
revision surgery did not otherwise occur in any patient.
In our group of young active-duty patients, there has
been 1 complication (8.5%), a postoperative wound
infection that required debridement and intravenous
antibiotics. This did not affect the reconstruction stability or the nal clinical or radiographic outcome. All of
the reconstructions remained stable at nal follow-up,
and no patient required revision surgery.
An advantage of the described surgical technique is that
it can be performed through small arthroscopic portals,
thus avoiding deltoid detachment and extensive soft-tissue
dissection while enabling excellent visualization of the
coracoid base during the graft transfer. The technique uses
the supracoracoid portal, which is located midway
between the medial border of the coracoid and the clavicle.
Lo et al.20 showed in their study on neurovascular structures around the coracoid that this area is safe. We use an
outside-in technique to optimize the placement of this
portal.
Geaney et al.21 found that the optimal bone density of
the clavicle is in the anatomic insertion area of the CC
ligaments between 20 mm and 50 mm from the lateral
edge of the clavicle. In our technique the tendon graft is
xed to the clavicle using 2 bone tunnels that are located
25 mm and 45 mm from the lateral end of the clavicle. The
present technique reproduces the anatomic insertion of
the 2 CC ligaments on the clavicle without drilling the
coracoid process. This potentially explains the lack of bone
fractures and the maintenance of xation stability in our
group of patients.

At a minimum follow-up of 24 months, we have found

marked improvement in the Constant score, Simple
Shoulder Test score, and level of pain. There was also a
good cosmetic result in all patients, and all patients
returned to preinjury levels of sports and job activity.
Limitations
Although this study is limited in that it includes a small
homogeneous cohort of young active-duty military male
patients, the cohort size compares favorably with similar
published studies.8,18 However, the ndings may not be
applicable to the broader population because of differences
in general health condition and bone quality, as well as
other anatomic considerations. In addition, although the
follow-up period is sufcient to assess the outcome after
the described procedure, a longer-term study including
more patients may identify additional potential complications. Lastly, the lack of a comparison group in the
published literature with high similarity to our patient
group confounds our ability to fully evaluate the outcome.

Conclusions
We present an arthroscopic technique for CC ligament reconstruction using an anatomic coracoid cerclage. This method showed good outcomes and
maintenance of radiographic reduction with high patient satisfaction and a low complication rate.

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12. Beitzel K, Cote MP, Apostolakos J, et al. Current concepts
in the treatment of acromioclavicular joint dislocations.
Arthroscopy 2013;29:387-397.
13. Dimakopoulos P, Panagopoulos A, Syggelos SA,
Panagiotopoulos E, Lambiris E. Double-loop suture repair
for acute acromioclavicular joint disruption. Am J Sports
Med 2006;34:1112-1119.
14. Fraschini G, Ciampi P, Scotti C, Ballis R, Peretti GM.
Surgical treatment of chronic acromioclavicular dislocation: Comparison between two surgical procedures for
anatomic reconstruction. Injury 2010;41:1103-1106.
15. Tauber M, Gordon K, Koller H, Fox M, Resch H. Semitendinosus tendon graft versus a modied Weaver-Dunn

16.

17.

18.

19.

20.

21.

procedure for acromioclavicular joint reconstruction in

chronic cases: A prospective comparative study. Am J
Sports Med 2009;37:181-190.
Simovitch R, Sanders B, Ozbydar M, Lavery K, Warner JJ.
Acromioclavicular joint injuries: Diagnosis and management. J Am Acad Orthop Surg 2009;17:207-219.
Milewski MD, Tompkins M, Giugale JM, Carson EW,
Miller MD, Diduch DR. Complications related to anatomic
reconstruction of the coracoclavicular ligaments. Am J
Sports Med 2012;40:1628-1634.
Coale RM, Hollister SJ, Dines JS, Allen AA, Bedi A.
Anatomic considerations of transclavicular-transcoracoid
drilling for coracoclavicular ligament reconstruction.
J Shoulder Elbow Surg 2013;22:137-144.
Cook JB, Shaha JS, Rowles DJ, Bottoni CR, Shaha SH,
Tokish JM. Early failures with single clavicular transosseous
coracoclavicular
ligament
reconstruction.
J Shoulder Elbow Surg 2012;21:1746-1752.
Lo IK, Burkhart SS, Parten PM. Surgery about the coracoid: Neurovascular structures at risk. Arthroscopy
2004;20:591-595.
Geaney LE, Beitzel K, Chowaniec DM, et al. Graft xation
is highest with anatomic tunnel positioning in acromioclavicular reconstruction. Arthroscopy 2013;29:434-439.

Arthroscopic Transtendinous Double-Pulley

Remplissage Technique in the Beach-Chair Position
for Large Hill-Sachs Lesions
Nata Parnes, M.D., MAJ Paul A. Carey, M.D., MC, USA, Christopher Schumacher, M.D.,
and Mark D. Price, M.D., Ph.D.

Abstract: Hill-Sachs lesions are a common nding in patients with glenohumeral instability. There have been numerous
methods described for addressing Hill-Sachs deformity. One popular method includes transferring a portion of the
infraspinatus muscle into the posterior-superior defect (remplissage) to prevent the lesion from engaging and the resultant
instability. We present a method of arthroscopic remplissage whereby the lesion is addressed through transtendinous
insertion of arthroscopic anchors. Once 2 anchors have been inserted, 1 limb of each suture is tied to the other anchor, the
so-called pulley repair technique. This can be performed either under direct visualization in the subacromial space or
blindly while the surgeon is viewing from the articular side. Once both limbs have been tied, the infraspinatus tendon
nicely spans the defect, and there has been minimal morbidity to the tendon itself. We have found this method to be useful
for addressing a large Hill-Sachs deformity.

osterosuperior humeral head impaction fractures

(Hill-Sachs lesions) occur in up to 88% of patients
with recurrent anteroinferior glenohumeral instability.1
Large Hill-Sachs lesions of the humeral head can engage
over the anterior glenoid rim when the arm is abducted
and externally rotated, resulting in recurrent anterior
instability and failure of an isolated labral repair.
A variety of open and arthroscopic techniques have
been described to treat engaging Hill-Sachs lesions
including humeral head and/or anterior glenoid rim
augmentation, rotational humeral osteotomies, partial
arthroplasties, capsular shifts, and tissue-lling techniques. In 2004 Wolf and Pollack2 described the
From Tri County Orthopedic Center (N.P.), Carthage; Fort Drum Army
Hospital (P.A.C.), Fort Drum, New York; and University of Massachusetts
Medical School and UMass Memorial Medical Center (C.S., M.D.P.),
Worcester, Massachusetts, U.S.A.
The authors report the following potential conict of interest or source of
funding: M.D.P. receives support from American Academy of Orthopaedic
Surgeons Anatomy and Imaging Evaluation Subcommittee, DePuy Mitek,
and Arthrex.
Received December 29, 2014; accepted March 5, 2015.
Address correspondence to Mark D. Price, M.D., Ph.D., UMass Memorial
Medical Center, Division of Sports Medicine, 281 Lincoln St, Worcester MA
01605, U.S.A. E-mail: mdprice00@gmail.com
2015 Arthroscopy Association of North America. Published by Elsevier
Inc. All rights reserved.
2212-6287/141082/$36.00
http://dx.doi.org/10.1016/j.eats.2015.03.001

arthroscopic technique of Hill-Sachs remplissage (French

for lling) performed in combination with Bankart
repair with the patient in the lateral decubitus position.
This technique has gained in popularity because of its
simplicity, short surgical time, good biomechanical and
clinical outcome, lack of need for graft augmentation, and
low rate of complications. Multiple variations of this
technique have been described with patients in the lateral
decubitus and beach-chair positions.
In 2009 Koo et al.3 described an arthroscopic doublepulley remplissage technique with the patient in the
lateral decubitus position, which provides a large footprint
xation but requires alternate visualization of the glenohumeral joint and the subacromial space. We present a
modication of this technique performed with the patient
in the beach-chair position using Healix Transtend anchors (Mitek, Raynham, MA) to achieve all-internal
remplissage xation.

Surgical Technique
The transtendinous double-pulley remplissage technique is similar to an arthroscopic transtendinous doublepulley repair of a partial-thickness, articular-surface
supraspinatus tendon repair. It essentially consists of xation of the infraspinatus tendon and posterior capsule to
the abraded surface of the Hill-Sachs lesion. The technique
described in this report was developed by the rst
author (N.P.) and simplies the double-pulley remplissage

Arthroscopy Techniques, Vol 4, No 4 (August), 2015: pp e305-e309

e305

e306

N. PARNES ET AL.

Table 1. Step-by-Step Remplissage Technique

Table 2. Pearls, Pitfalls, Key Points, and Indications

1. Position the patient in the beach-chair position.

2. Perform diagnostic arthroscopy through the posterolateral portal
and the anterolateral portal.
3. Clear the subacromial space posteriorly and posterolaterally.
4. Place and pass glenoid sutures/anchors without tying them.
5. Prepare the Hill-Sachs bony bed.
6. Insert the trocar-tipped guidewire for the Healix Transtend anchor
through the posterior cannula, infraspinatus tendon, and
posterior capsule, locating it at the inferior aspect of the HillSachs lesion, next to the articular margin.
7. Use a 4-mm designated cannula over the guidewire to place the
Healix Transtend anchor at the desired location.
8. Repeat steps 6 and 7 with a second Healix Transtend anchor, and
place it at the superior aspect of the Hill-Sachs lesion.
9. Viewing from the anterosuperior portal and working through the
anteroinferior portal, tie the glenoid sutures.
10. Through the posterior 8.5-mm cannula, tie the sutures from the 2
anchors using the double-pulley technique.
11. Verify the quality of the repair on both intra-articular and
subacromial views.

Pearls
The procedure can be performed with the patient in the beachchair or lateral decubitus position.
It is important to perform preliminary subacromial bursectomy
with special attention to the posterior and posterolateral
gutters to prevent interposition of bursal tissue during the
knot-tying stage.
When the surgeon is performing arthroscopy through the
anterosuperior portal, a 70 arthroscope allows better viewing
of the Hill-Sachs lesion, although a 30 arthroscope can still
provide adequate visualization.
While the surgeon is preparing the bony bed of the Hill-Sachs
defect, it is important to be gentle and remove a minimal
amount of surface bone.
During the procedure, the cannula has to be withdrawn from the
posterior capsule and the infraspinatus tendon but not through
the deltoid.
The arm should be positioned in slight abduction and neutral
rotation.
While the surgeon is inserting the anchors, it is important to angle
the guide perpendicular to the lesion or slightly from medial to
lateral to reduce the risk of penetrating the articular surface.
The 70 arthroscope should be used through the anterosuperior
portal and the anterior portal to verify that the rst anchor has
been placed in the most inferior area of the Hill-Sachs defect.
The second anchor should be placed in the most superior area of
the Hill-Sachs defect.
The surgeon should verify that the sutures on both anchors slide
easily.
While tying the sutures from the 2 anchors in the double-pulley
technique, the surgeon should verify that the rst knot is stable
and does not slip before pulling it into the subacromial space.
The nal tissue xation to the Hill-Sachs defect should be
performed by tying arthroscopic nonsliding knots in the
subacromial space and should be conrmed on both intraarticular and subacromial views.
At the end of the procedure, the humeral head should be centered
on the glenoid when viewing through the anterosuperior
portal.
Pitfalls
Failure of 1 of the 2 anchors will lead to failure of the doublepulley xation.
If the choice is made to view the knots being tied in the
subacromial space, the surgeon must be sure to perform the
subacromial bursectomy before anchor insertion; otherwise,
damage to the sutures is possible or even likely.
Key points
This technique simplies the double-pulley technique of Koo
et al.3 by using the Transtend anchor system.
The double-pulley technique provides a large footprint xation.
The technique is simple and less time-consuming than previously
described techniques for remplissage.
Indications
Intraoperative evidence of engagement of Hill-Sachs defect
Moderate to large Hill-Sachs defect (>3 mm in depth) associated
with bony glenoid loss <25%
Borderline arthroscopic cases in which bone defect is close to 25%
but Hill-Sachs defect is small to moderate in size

technique of Koo et al.3 by using the Healix Transtend

anchor system. Video 1 demonstrates this method in its
entirety. The steps of the procedure are outlined in Table 1,
and pearls, pitfalls, key points, and indications are shown
in Table 2.
Under general anesthesia, the patient is placed in a
modied beach-chair position and the arm is placed into
a Spider articulated arm holder (Tenet Medical, Calgary,
Alberta, Canada) that allows for free positioning in space.
The arthroscope is introduced into the glenohumeral
joint through a posterolateral portal that is placed at the
lateral aspect of the convexity of the humeral head so
that it is centered directly over the Hill-Sachs lesion. This
portal will allow visualization of the joint during the
anterior labral repair, as well as working access to abrade
the surface of the Hill-Sachs lesion and suture management during the transtendinous double-pulley repair. An
anteroinferior portal is made in the rotator interval,
which will be the primary working portal for the anterior
labral repair. By use of a spinal needle, an anterosuperior
portal is placed immediately posterior to the biceps
tendon by an outside-in technique. This portal will allow
suture management during the anterior labral repair
and visualization of the Hill-Sachs lesion during the
remplissage procedure.
We rst perform diagnostic glenohumeral arthroscopy
through the posterior portal and then through the anterosuperior portal. We assess the anterior labral lesion, the
amount of glenoid bone loss, and the size of the Hill-Sachs
lesion, and we determine whether the Hill-Sachs lesion is
engaging while the arm is in abduction and external
rotation.
Our indications for the remplissage procedure include
a moderate to large Hill-Sachs defect (>3mm in depth)
associated with bony glenoid loss of less than 25% or a
small to moderate Hill-Sachs defect associated with
glenoid bone loss close to 25%. Any Hill-Sachs lesion

associated with glenoid bone loss greater than 25% is

addressed with the Latarjet procedure.
A subacromial bursectomy is performed with special
attention to the posterior and posterolateral gutters to
prevent interposition of bursal tissue during the knot-tying

DOUBLE-PULLEY REMPLISSAGE

Fig 1. Hill-Sachs deformity (HS) of the left shoulder viewed from

the anterosuperior portal with the patient in the beach-chair
position. The lesion has been prepared with extensive rasping
to create a good bed of bleeding bone for better ingrowth of the
infraspinatus tendon once it is pulled into the lesion. (AS, articular surface.)

stage. Once the subacromial space has been prepared, the

arthroscope is again placed intra-articularly.
Viewing from the posterior portal and instrumenting
through the anteroinferior and anterosuperior portals,
the surgeon mobilizes the labral tear and inferior glenohumeral ligament and repairs the labrum with suture
anchors. The sutures are passed through the anteroinferior portal and left untied.
The camera is switched from the posterior portal to the
anterosuperior portal; we have found that a 70 arthroscope allows better viewing of the Hill-Sachs lesion at this
point. An 8.5-mm threaded cannula is placed over a
switching stick in the posterior portal. Through the

Fig 2. Guidewire insertion. The transtendinous needle is

inserted percutaneously through the infraspinatus and posterior
capsule to a point at the inferior margin of the Hill-Sachs lesion.
This will be used to guide anchor placement.

e307

Fig 3. First anchor insertion. A transtendinous anchor is

placed through a metal cannula that has been inserted over
the guidewire. This is a single-loaded titanium anchor.

posterior cannula, using an arthroscopic rasp, the surgeon

gently abrades the surface of the Hill-Sachs lesion. Special
care is taken to remove a minimal amount of surface bone
(Fig 1). The surface of the entire posterior and inferior
capsule is gently freshened with a whisker blade.
While maintaining the camera in the anterosuperior
portal, the surgeon carefully withdraws the cannula in the
posterior portal from the posterior capsule and the infraspinatus tendon but not through the deltoid. The arm is
positioned in slight abduction and neutral rotation.
The trocar-tipped guidewire for the Healix Transtend
anchor is inserted through the posterior cannula, infraspinatus tendon, and posterior capsule and placed at the
inferior aspect of the Hill-Sachs lesion, next to the articular
margin. The 4-mm cannula and obturator assembly are
placed over the guidewire. Next, removing the guidewire
and obturator, the surgeon leaves only the 4-mm cannula
through the infraspinatus tendon and posterior joint
capsule. The awl and Healix Transtend anchor are then
placed through the cannula. With the sutures exiting the
posterior cannula, the aforementioned sequence of steps
is repeated to place a second Healix Transtend anchor at
the superior aspect of the Hill-Sachs lesion, next to the
articular margin (Figs 2-4). Once the Hill-Sachs anchors
have been placed, the anteroinferior capsulolabral repair
is completed by tying the sutures. We use the doublepulley technique to tie the sutures in the Hill-Sachs
lesion to each other outside of the shoulder and in the
subacromial space, completing the remplissage.
Final intra-articular and subacromial views conrm the
completed repair (Fig 5). Our end goal is to obtain an
anatomic labral repair with the humeral head centered on
the glenoid when viewing through the anterosuperior
portal.
The postoperative protocol consists of use of an external
rotation shoulder immobilizer to maintain the shoulder in

e308

N. PARNES ET AL.

Fig 4. Second anchor insertion. This anchor is inserted in the

same manner as the rst but at the superior aspect of the HillSachs lesion. One limb from each suture is tied together in a
double-pulley fashion to ll the Hill-Sachs defect with the
infraspinatus tendon.

neutral rotation. This helps decrease tension on the posterior repair. Immobilization is maintained for 4 to
6 weeks. Immediate isometric and elbow range-of-motion
exercises are allowed. At the 6-week mark, a program of
active and active-assisted motion exercises is begun.
Increased active strengthening exercises are implemented
at the 12-week mark. Return to full activity and sports is
allowed at approximately 5 to 6 months after surgery.

Discussion
Over 95% of shoulder dislocations are anterior.4 During
anterior shoulder dislocation, the head of the humerus
forcefully displaces out of the glenoid socket, avulsing
anterior bony and soft-tissue structures in the process
(Bankart lesion).4 As the posterior part of the humeral
head exits the joint and the soft cancellous bone of the
posterosuperior humeral head collides with the dense
cortical anterior rim of the glenoid, a bony indentation at
the back of the humeral head may be created (Hill-Sachs
lesion).5 These bony lesions are an important cause
of recurrent shoulder instability and failure of Bankart
repairs.6-8 In particular, lesions that engage the rim of the
glenoid when the shoulder is in a position of abduction
and external rotation, so-called engaging Hill-Sachs lesions, are associated with recurrent instability.6,9-11 A
variety of anatomic and nonanatomic surgical techniques
have been described to address Hill-Sachs lesions that are
large, engaging, or associated with recurrent instability,
including humeral head augmentation, disimpaction,
and resurfacing12-15; glenoid bone augmentation16-18;
and rotational humeral osteotomy.19 These techniques
might achieve good stabilization of the shoulder, but they
also are associated with complications including
nonunion, neurovascular damage, implant malfunction,

disease transmission by allograft, glenohumeral arthritis,

and increased cost.20,21
Connolly22 in 1972 described an open surgical technique to insert the infraspinatus muscle into a
Hill-Sachs defect to eliminate the engagement of the
Hill-Sachs deformity. In 2004 Wolf and Pollack2
described an arthroscopic approach to insert the infraspinatus muscle into a Hill-Sachs deformity and used
the term remplissage (French for lling) for this
procedure. Their technique quickly gained in popularity
because of its simplicity, good clinical outcome, low
complication rate, low cost, and lack of requirement for
additional implant or graft material.23-27 The remplissage technique uses a nonanatomic solution to treat the
Hill-Sachs lesion and stabilize the glenohumeral joint.
The technique requires tethering of the infraspinatus,
which has raised the concern of loss of internal rotation.
Despite this concern, no signicant loss of internal
rotation has been found in patients who have undergone this procedure.23-27
Koo et al.3 described a modication of the classic
remplissage procedure using the double-pulley technique.
This technique potentially offers the advantage of
providing a large footprint xation and rmly setting the
infraspinatus tendon into the Hill-Sachs defect. Their
group of patients showed good outcomes with no loss of
internal rotation.
The technique described in our report is a modication
of the double-pulley technique using Healix Transtend
anchors through the posterior cannula. This modication
has several advantages, including the ability to perform the
entire technique while viewing in the glenohumeral joint,
thus eliminating the need to alternate the view between
the glenohumeral joint and the subacromial space. This in
turn eliminates the need to use spinal needles and multiple
portals, which potentially make this procedure more accurate. Most importantly, this modication makes the

Fig 5. After both limbs have been tied together, the infraspinatus tendon in nicely positioned into the Hill-Sachs defect.
Joint congruency and stability have been restored.

DOUBLE-PULLEY REMPLISSAGE

surgical technique simpler and, in our experience, significantly reduces surgical time. We believe that using the
Healix Transtend anchor modication of the doublepulley remplissage technique allows a large footprint xation of the infraspinatus tendon into the Hill-Sachs defect
in a simple, accurate, time-saving way.

References
1. Yiannakopoulos CK, Mataragas E, Antonogiannakis E.
A comparison of the spectrum of intra-articular lesions in
acute and chronic anterior shoulder instability. Arthroscopy
2007;23:985-990.
2. Wolf EM, Pollack ME. Hill-Sachs remplissage: An
arthroscopic solution for the engaging Hill-Sachs lesion
(SS-32). Arthroscopy 2004;20:e14-e15 (abstr).
3. Koo SS, Burkhart SS, Ochoa E. Arthroscopic doublepulley remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs. Arthroscopy
2009;25:1343-1348.
4. Bankart ASB. The pathology and treatment of recurrent
dislocations of the shoulder joint. Br J Surg 1938;26:23-29.
5. Hill HA, Sachs MD. The grooved defect of the humeral
head: A frequently unrecognized complication of dislocations of the shoulder joint. Radiology 1940;35:690-700.
6. Burkhart SS, De Beer JF. Traumatic glenohumeral bone
defects and their relationship to failure of arthroscopic
Bankart repairs. Arthroscopy 2000;16:677-694.
7. Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent
causes of failure and treatment. J Bone Joint Surg Am
1984;66:159-168.
8. Lynch JR, Clinton JM, Dewing CB, Warme WJ,
Matsen FA III. Treatment of osseous defects associated
with anterior shoulder instability. J Shoulder Elbow Surg
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9. Warner JJ, Bowen MK, Deng XH, Hannan JA, Arnoczky SP,
Warren RF. Articular contact patterns of the normal glenohumeral joint. J Shoulder Elbow Surg 1998;7:381-388.
10. Boileau P, Villalba M, Hery JY, Balg F, Ahrens P,
Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg
Am 2006;88:1755-1763.
11. Cetik O, Uslu M, Ozsar BK. The relationship between HillSachs lesion and recurrent anterior shoulder dislocation.
Acta Orthop Belg 2007;73:175-178.
12. Gerber C, Lambert SM. Allograft reconstruction of
segmental defects of the humeral head for the treatment
of chronic locked posterior dislocation of the shoulder.
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13. Kazel MD, Sekiya JK, Greene JA, Bruker CT. Percutaneous correction (humeroplasty) of humeral head defects
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14. Snir N, Wolfson TS, Hamula MJ, Gyftopoulos S,

Meislin RJ. Arthroscopic anatomic humeral head reconstruction with osteochondral allograft transplantation for
large Hill-Sachs lesions. Arthrosc Tech 2013;2:e289-e293.
15. Kropf EJ, Sekiya JK. Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability. Arthroscopy 2007;23:322.e1-322.e5.
16. Boileau P, Bicknell RT, El Fegoun AB, Chuinard C.
Arthroscopic Bristow procedure for anterior instability in
shoulders with a stretched or decient capsule: The beltand-suspenders operative technique and preliminary
results. Arthroscopy 2007;23:593-601.
17. Ghodadra N, Gupta A, Romeo AA, et al. Normalization of
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iliac crest bone-grafting. J Bone Joint Surg Am 2010;92:
1478-1489.
18. Provencher MT, Ghodadra N, LeClere L, Solomon DJ,
Romeo AA. Anatomic osteochondral glenoid reconstruction for recurrent glenohumeral instability with glenoid
deciency using a distal tibia allograft. Arthroscopy
2009;25:446-452.
19. Weber BG, Simpson LA, Hardegger F. Rotational humeral
osteotomy for recurrent anterior dislocation of the
shoulder associated with a large Hill-Sachs lesion. J Bone
Joint Surg Am 1984;66:1443-1450.
20. Bigliani LU, Weinstein DM, Glasgow MT, Pollock RG,
Flatow EL. Glenohumeral arthroplasty for arthritis after
instability surgery. J Shoulder Elbow Surg 1995;4:87-94.
21. Green A, Norris TR. Shoulder arthroplasty for advanced
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23. Park MJ, Tjoumakaris FP, Garcia G, Patel A, Kelly JD IV.
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25. Haviv B, Mayo L, Biggs D. Outcomes of arthroscopic
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Hill-Sachs lesion. J Orthop Surg Res 2011;6:29.
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Zumstein M. Anatomical and functional results after
arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am
2012;94:618-626.
27. Franceschi F, Papalia R, Rizzello G, et al. Remplissage
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shoulder instability: A 2-year follow-up comparative
study. Am J Sports Med 2012;40:2462-2469.

Technical Note

The Double-Pulley Anatomic Technique for Type II

SLAP Lesion Repair
Nata Parnes, M.D., Mario Ciani, D.C., Brian Carr, M.D., and Paul Carey, M.D.

Abstract: The annual incidence and number of repairs of SLAP lesions in the United States are constantly increasing.
Surgical repairs of type II SLAP lesions have overall good success rates. However, a low satisfaction rate and low rate of
return to preinjury level of play remain a challenge with elite overhead and throwing athletes. Recent anatomic studies
suggest that current surgical techniques over-tension the biceps anchor and the superior labrum. These studies suggest
that restoration of the normal anatomy will improve clinical outcomes and sports performance. We present a doublepulley technique for arthroscopic xation of type II SLAP lesions. In this technique the normal anatomy is respected by
preserving the mobility of the articular aspect of the superior labrum while reinforcing the biceps anchor and its posterior
bers medially.

igh physical demands and training requirements

make SLAP tears a common cause of shoulder pain
and disability among athletes involved in overhead activities.1 The annual incidence and number of repairs of SLAP
lesions in the United States are constantly increasing.2
Multiple arthroscopic type II SLAP lesion repair
techniques have been described, with good to excellent
outcomes in most cases. However, the results in
throwing or overhead athletes are much less satisfying
especially because of residual pain, stiffness, and a poor
return to preinjury level of performance.3
Most of the arthroscopic repair techniques focus on
the stability of the superior labrum xation and less on
restoration of the patients anatomy. Better understanding and restoration of the native anatomy will
probably improve clinical outcomes and rates of return
to preinjury level of performance.4
Recent anatomic studies have improved our understanding of the anatomic alterations that result from
From the Tri County Orthopedic Center (N.P.), Carthage, New York;
Clarkson University (M.C.), Potsdam, New York; and Department of Orthopaedic Surgery, Guthrie Army Health Clinic (B.C., P.C.), Fort Drum, New
York, U.S.A.
The authors report that they have no conicts of interest in the authorship
and publication of this article.
Received February 16, 2015; accepted May 21, 2015.
Address correspondence to Paul Carey, M.D., Department of Orthopaedic
Surgery, Guthrie Army Health Clinic, 11050 Mt Belvedere Rd, Fort Drum,
NY 13602-5004, U.S.A. E-mail: paul.a.carey6.mil@mail.mil
Published by Elsevier Inc. on behalf of the Arthroscopy Association of North
America
2212-6287/15157/$36.00
http://dx.doi.org/10.1016/j.eats.2015.05.009

Arthroscopy Techniques, Vol

-,

SLAP tears and the normal anatomy of the long head of

biceps tendon footprint insertion to the upper labrum
and supraglenoid tubercle. These studies have drawn
some guidelines for optimal SLAP lesion repair technique.5,6 In this article we describe a double-pulley
technique for anatomic repair of the superior labrum
and biceps anchor using these guidelines (Tables 1 and
2).

Surgical Technique
This technique was developed by the rst author
(N.P.). It uses the double-pulley suture conguration
for type II SLAP lesion repair. The patient is placed in
the beach-chair position using a Spider Limb Positioner
(Tenet Medical, Calgary, Alberta, Canada) to hold the
arm in the desired position. A 30 arthroscope is
introduced into the glenohumeral joint through a
standard posterior portal. An anterosuperior portal is
established high in the rotator interval region using a
spinal needle by an outside-in technique. The needle is
replaced with an 8.25-mm arthroscopic shoulder
cannula.
A complete diagnostic arthroscopy of the glenohumeral joint is performed. Associated intra-articular
pathology is documented and addressed as indicated.
Then, by use of a probe, the type II SLAP lesion is
conrmed by the existence of a complete detachment
of the biceps anchor from the supraglenoid tubercle
(Fig 1). Once the lesion is veried, a transerotator cuff
portal is created medial to the rotator cuff cable (at the
musculotendinous junction) using a spinal needle as
described by OBrien et al.7

No

(Month), 2015: pp e1-e6

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N. PARNES ET AL.

Table 1. Step-by-Step Double-Pulley Anatomic Technique

1. Position the patient in the beach-chair position.
2. Perform diagnostic arthroscopy through the posterior portal and anterior portal (place 8.5-mm cannulas in both portals).
3. Use a spinal needle and No. 11 blade to place a trans-cuff portal medial to the rotator cuff cable while viewing from posterior (place a 5.5-mm
smooth cannula over a switching stick).
4. Use a rasp and 4.5-mm shaver to prepare the superior glenoid neck and superior labrum.
5. Through the trans-cuff portal, place a Suturex 1.9-mm double-loaded anchor at the 10-oclock position (right shoulder).
6. Use a shuttling device to retrieve 1 arm of the suture from the anchor through the superior-posterior labrum.
7. Through the trans-cuff portal, use an arthroscopic simple vertical knot-tying technique to x the superior-posterior labrum.
8. Through the posterior portal, use a shuttling device to retrieve the 2 arms of the other suture on the anchor through the superior-posterior
labrum.
9. Through the anterior portal, place a Suturex 1.7-mm single-loaded anchor in line with the anterior edge of the biceps tendon.
10. Through the anterior portal, use a shuttling device to retrieve the 2 arms of the suture on the anchor through the superior-anterior labrum.
11. Retrieve the 4 limbs through the trans-cuff portal (superior to the biceps tendon).
12. Through the trans-cuff cannula, tie the sutures from the 2 anchors using the double-pulley technique.

With the arthroscope placed in the posterior portal, a

4.5-mm shaver is used through the anterosuperior
portal to debride the superior glenoid neck to bleeding
bone and the edge of the superior labrum as indicated
(Fig 2). Through a smooth cannula placed in the transe
rotator cuff portal, a Suturex 1.9-mm double-loaded
anchor (Smith & Nephew, Andover MA) is placed at
the 10-oclock position for a right shoulder (Fig 3). The
surgeon retrieves 3 suture arms through the anterosuperior portal, leaving 1 suture end in the transe
rotator cuff portal. Viewing through the transerotator
cuff portal, the surgeon uses a 45 right lasso-loop device
through the posterior portal to shuttle the remaining
suture arm through the superior-posterior labrum. The
suture is passed at a point where the position of the
labrum does not change with shoulder motion. With the
arthroscope placed in the posterior portal, an arthroscopic simple vertical knot-tying technique is used

through the transerotator cuff portal (Fig 4). The 45

right lasso-loop device is used again through the posterior portal to shuttle the other 2 arms of the second
suture on the anchor through the superior-posterior
labrum (Fig 5). The arthroscope is transferred to the
posterior portal. Then, by use of the anterosuperior
portal, a Suturex 1.7-mm single-loaded anchor (Smith
& Nephew) is placed on the glenoid rim in line with the
anterior edge of the biceps insertion (Fig 5). Both suture
arms are retrieved through the transerotator cuff portal.
A 45 left lasso-loop device is used through the anterosuperior portal to shuttle the 2 arms through the
superior-anterior labrum in line with the anterior edge
of the biceps tendon.
Using a suture manipulator, the surgeon retrieves the
4 limbs of the 2 sutures through the transerotator cuff
portal, taking care to retrieve the suture limbs from the
anterior anchor superior to the biceps tendon (Fig 6).

Table 2. Indications, Advantages, Disadvantages, Pearls, and Pitfalls of Arthroscopic Double-Pulley Type II SLAP Lesion Repair
Indications
Symptomatic type II SLAP lesions in patients aged <40 yr with normal biceps tendons.
Advantages
Stable horizontal xation is achieved while maintaining the freedom of the superior labral edge.
The technique provides a broad area of compression of the biceps anchor and posterior-superior labral periosteal sleeve against the native
bone bed of the glenoid neck.
The technique is suitable for large and complex type II SLAP tears.
A watertight repair of the posterior-superior labral periosteal sleeve is produced; this is especially important when a paralabral cyst is present.
Using 2 separate anchors eliminates the risk of biceps tendon strangulation.
Disadvantages
The procedure is longer and has higher costs than a single-anchor repair.
Failure of 1 of the 2 anchors will lead to total failure of the double-pulley xation.
Pearls
Use a spinal needle in an outside-in technique to place the transerotator cuff portal medial to the supraspinatus cable to avoid damage to the
tendon.
Place the posterior anchor on the glenoid rim at a point where the appearance of the labrum does not change with shoulder motion
(10-oclock position for a right shoulder) and not at the biceps base.
Remember that the horizontal biceps anchor xation should not extend anteriorly to the anterior edge of the biceps tendon on the labrum.
Verify that both sutures are sliding freely before performing the double-pulley part of the technique.
Pitfalls
When drilling the glenoid rim for the anterior anchor placement, be careful not to drill into the posterior anchor.
If MGHL and SGHL reconstruction is elected, avoid xing them with the same suture used for the biceps xation.
MGHL, middle glenohumeral ligament; SGHL, superior glenohumeral ligament.

TYPE II SLAP LESION REPAIR

Fig 1. With viewing through the posterior portal, the type II

SLAP lesion is conrmed by the existence of a complete
detachment of the biceps anchor from the supraglenoid tubercle using a probe. This image and Figures 2-9 show the
same left shoulder with the patient in the beach-chair
position.

e3

Fig 3. With viewing through the posterior portal, a Suturex

1.9-mm double-loaded anchor is placed at the 10-oclock
position through a transerotator cuff portal.

One suture limb for each anchor is chosen to be coupled

in a double-pulley conguration (Fig 7). Once the
double pulley is completed, xation of the biceps anchor is completed with tightening of non-sliding knots
on the remaining suture limbs of each anchor (Fig 8).
At the end of the procedure, the adequacy of the repair
is conrmed with a probe (Fig 9). The shoulder is taken
through a full range of motion to rule out tension on
the repair that can lead to stiffness.

The postoperative protocol consists of sling immobilization for 4 weeks. Early pendulum shoulder exercises
and distal range-of-motion exercises involving the
elbow, wrist, and hand are initiated immediately. Passive range of motion of the shoulder should be started
during the rst 2 weeks postoperatively, with a gradual
progression of forward exion from 90 to 150 over a
period of 6 weeks. Active range of motion of the
shoulder and a progressive strengthening program start
at 6 weeks after surgery. Return to unrestricted activities, including vigorous sports, is permitted at 6 months
postoperatively.

Fig 2. With viewing through the posterior portal, a 4.5-mm

shaver is used through the anterosuperior portal to debride
the superior glenoid neck to bleeding bone and the edge of the
superior labrum as indicated.

Fig 4. An arthroscopic simple vertical knot is used to x the

posterior portion of the tear where the appearance of the
articular edge of the labrum does not change with shoulder
motion.

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N. PARNES ET AL.

Fig 5. The 2 arms of the second suture on the anchor are

shuttled through the superior-posterior labrum. By use of the
anterosuperior portal, a Suturex 1.7-mm single-loaded anchor is placed on the glenoid neck in line with the anterior
edge of the long head of the biceps tendon.

Discussion

Fig 7. One suture limb for each anchor is chosen to be

coupled in a double-pulley conguration.

The disappointing outcomes of type II SLAP lesion

repair in elite athletes motivated surgeons to further
investigate alternative solutions for this injury. Patient
subjective satisfaction levels and rates of return to
previous level of sports activity have been found to be
better with biceps tenodesis8 when compared with
SLAP lesion repair using suture anchor xation. Previously described techniques for type II SLAP lesion

repair mostly addressed labral stability and not the

anatomic restoration of the biceps anchor and superior
labrum.
Recent anatomic and biomechanical studies have
improved our understanding of the pathologic changes
that occur with a SLAP tear and the normal anatomy
and function of the superior labrum and long head of

Fig 6. A shuttling device is used to retrieve the 2 arms of the

suture on the anterior anchor through the superior-anterior
labrum. The surgeon retrieves the 4 limbs of the 2 sutures
through the transerotator cuff portal, paying attention to
retrieve the suture limbs from the anterior anchor superior to
the biceps tendon to prevent entanglement.

Fig 8. Fixation of the long head of the biceps tendon anchor is

completed with tightening of non-sliding knots on the
remaining suture limbs of each anchor. As viewed from
above, the completed double-pulley construct secures the
biceps anchor bers medially between 2 suture anchors.

TYPE II SLAP LESION REPAIR

Fig 9. At the end of the procedure, the adequacy of the repair

is conrmed using a probe.

biceps tendon. Strauss et al.9 in a biomechanical study

found that biceps tenodesis is unable to completely
restore translational stability of the glenohumeral joint
and should be considered with caution as the primary
treatment for SLAP lesions in overhead throwing athletes. Several studies have suggested that overtensioning the biceps anchor and the superior labrum
during SLAP lesion repair may lead to residual stiffness
and pain and that a more anatomic reconstruction will
lead to a better clinical outcome.4-6
Recommend guidelines for a repair technique that
respects the normal anatomy and functional demands
of the superior labrum and biceps anchor include the
following5,6: (1) The biceps anchor should be repaired
to the supraglenoid tubercle (approximately 6 mm
medial to the glenoid face) in a horizontal fashion to
maintain the free edge of the superior labrum. (2) The
horizontal biceps anchor xation should not extend
anteriorly to the anterior edge of the biceps tendon on
the labrum. (3) The posterior portion of the tear where
the appearance of the labrum does not change with
shoulder motion (10-oclock position for a right
shoulder) should be xed in a simple vertical suture
conguration. (4) If reconstruction of the middle glenohumeral ligament (MGHL) and superior glenohumeral ligament (SGHL) is elected to be performed, it
should be performed using a separate suture knot
rather than the one used for the biceps anchor xation
to maintain their independent functions (Video 1). The
surgical technique detailed in this report incorporates
all these anatomic and biomechanical guidelines by
using the double-pulley technique.
The double-pulley technique has been described as
providing stable xation with a broad area of tissue
compression against the native bone bed in cases of
bony Bankart repair,10 rotator cuff repair,11 remplissage

e5

procedure,12 and avulsion fracture of the greater tuberosity.13 In the described surgical procedure, the
double-pulley technique creates a stable horizontal
xation of the biceps anchor while maintaining the
mobility of the superior labral edge. It also provides a
broad area of compression of the biceps anchor and
posterior-superior labral periosteal sleeve against the
native bone bed of the glenoid neck, which increases
the probability of the soft tissue healing to the bone.
Burkhart et al.14 suggested that in type II SLAP lesion
repairs, posterior xation is the most important factor
in resisting peel-back forces during the late cocking
phase. This assertion was later supported in a cadaveric
study that showed that a single posterior xation is
enough to eliminate peel-back of the labrum.15
Anatomic studies suggest that the rigidity of the labral
xation is more important than its exibility at this
posterior portion of the tear where the appearance of
the labrum does not change with shoulder motion. In
the double-pulley anatomic technique, we use a simple
vertical suture conguration for the posterior nonmobile labral xation. This simple vertical suture provides a stronger initial xation than a horizontal
mattress suture.16 The use of 2 separate anchors in the
double-pulley technique allows coverage of an extensive area of attachment of the biceps anchor to the
posterior glenoid neck while eliminating the risk of
biceps tendon strangulation that exists in a 1-anchor
xation.
Reconstruction of the insertion of the MGHL and
SGHL to the anterior-superior labrum as part of a type
II SLAP lesion repair is still a debatable issue. Although
some studies have supported it as part of reconstructing
the normal anatomy and joint stability, others have
expressed concerns of creating excessive stiffness and
loss of external rotation (ER). Castagna et al.4 reported
that, using their surgical technique, which included
reconstruction of the insertion of the MGHL and SGHL,
the mean passive abduction, ER with the arm at the
side, and ER with 90 of abduction did not differ after
the surgical reconstruction. More importantly, all
throwing athletes returned to their preinjury level of
sports activity.
McCulloch et al.17 in a cadaveric study found that
anterior-superior xation resulted in a small but statistically signicant decrease in ER. They recommended
considering avoidance of an anterior-superior xation
when performing SLAP lesion repair in athletes for
whom even a small loss of ER would be detrimental.
Clinical studies show that the most common complication of SLAP lesion repair in elite athletes is excessive
stiffness and loss of ER.18,19 In the described surgical
technique, we avoid using xation anterior to the
anterior edge of the biceps tendon on the labrum.
Surgeons who wish to reconstruct the MGHL and SGHL
anterior to the biceps tendon can easily modify the

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N. PARNES ET AL.

surgical technique by using a double-loaded anchor

instead of the single-loaded anchor at the anteriorsuperior glenoid area. The extra suture on the anchor
can be used to perform a vertical simple stitch at the
level of the insertion of the MGHL and SGHL.
There is no consensus regarding the use of a transe
rotator cuff portal during SLAP lesion repair. The
double-pulley anatomic technique can be performed as
described or without the use of the transerotator cuff
portal depending on the surgeons preference. If
avoiding the use of the transerotator cuff portal is
elected, we recommend tying the double-pulley knots
through the anterior portal while viewing from the
posterior portal so that the knot will be medial to the
biceps tendon insertion. This knot position reduces the
risk of rotator cuff impingement against it.
This report describes an arthroscopic double-pulley
technique to repair type II SLAP lesions. This technique is based on recent anatomic and biomechanical
ndings. Further clinical outcome studies are required
to validate the theoretical benets of this technique.

Acknowledgment
The authors thank Itai Parnes for technical support.

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