The “Pull-Over” Technique for Arthroscopic Superior Capsular Reconstruction A. Ali Narvani, M.B.B.S.(Hons), B.Sc.(Hons), M.Sc.(Sports Med.)(Hons), F.R.C.S.(Orth & Trauma), M.F.S.E.M.(UK), Paolo Consigliere, M.D., M.Ch.(Ortho & Trauma), Ioannis Polyzois, M.B.Ch.B., M.R.C.S., C.C.S.T.Orth., F.E.B.O.T., Tanaya Sarkhel, M.B.B.S., F.R.C.S.(Orth & Trauma), Rohit Gupta, M.B.B.S., F.R.C.S.(Orth & Trauma), Ofer Levy, M.D., M.Ch.(Orth), F.R.C.S. Arthroscopy Techniques Volume 5, Issue 6, Pages e1441-e1447 (December 2016) DOI: 10.1016/j.eats.2016.08.016 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions
Fig 1 Insertion of the glenoid anchors. (Arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position.) Arthroscopy Techniques 2016 5, e1441-e1447DOI: (10.1016/j.eats.2016.08.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions
Fig 2 Preparation of the extracellular matrix outside the patient. Arthroscopy Techniques 2016 5, e1441-e1447DOI: (10.1016/j.eats.2016.08.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions
Fig 3 (A) Polydioxanone sutures (PDSs) are tied to the sutures limbs of each anchor just outside the Neviaser port. (B) Suture limbs of both anchors are then brought out through the lateral cannula while holding on to the one end of each PDS outside the Neviaser port. (Arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position.) Arthroscopy Techniques 2016 5, e1441-e1447DOI: (10.1016/j.eats.2016.08.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions
Fig 4 (A) The polydioxanone sutures (PDSs) are untied from the anchor suture limbs outside the lateral port. (B) The suture limbs of anterior anchor are passed through the anterior hole of the patch and those of the posterior anchor through the posterior hole. (C) The PDS ends outside the lateral port are then tied to the anchor suture limbs again. (D) The PDS ends are pulled to bring out the all suture limbs of the anchors through the Neviaser port. Arthroscopy Techniques 2016 5, e1441-e1447DOI: (10.1016/j.eats.2016.08.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions
Fig 5 All suture limbs are shuttered out through the Neviaser port after being passed through the augment. Arthroscopy Techniques 2016 5, e1441-e1447DOI: (10.1016/j.eats.2016.08.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions
Fig 6 (A) Anchor suture limbs outside the Neviaser port are all pulled, therefore, pulling over (“pull-over” technique) the matrix into the bursa. (Arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position.) (B) Once inside the subacromial space, the patch is laid open flat using a blunt obturator. (Arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position.) Arthroscopy Techniques 2016 5, e1441-e1447DOI: (10.1016/j.eats.2016.08.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions
Fig 7 Matrix is secured to the glenoid. (Arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position.) Arthroscopy Techniques 2016 5, e1441-e1447DOI: (10.1016/j.eats.2016.08.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions
Fig 8 (A) One or two medial row anchors may be used. (Arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position.) (B) Suture limbs are passed through the matrix using a suture passer. (Arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position.) (C) Once all suture limbs are passed through the matrix, they are tied using standard knot tying techniques. (D) Lateral row anchors are inserted. Arthroscopy Techniques 2016 5, e1441-e1447DOI: (10.1016/j.eats.2016.08.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions
Fig 9 (A) Final construct view from the bursa looking from the lateral port showing the secured medial augment edge on the glenoid. (B) Final construct view from the bursa looking from the lateral port showing the secured lateral augment edge on the greater tuberosity. (C) Final construct view from the glenohumeral joint. (Arthroscope is in the standard posterior port of the right shoulder with the patient in the lateral position, but the arthroscope is rotated so the images appear as though the patient is in the beach chair position.) Arthroscopy Techniques 2016 5, e1441-e1447DOI: (10.1016/j.eats.2016.08.016) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions