1. Multidirectional Shoulder Instability: Arthroscopic Labral Augmentation 
Enrico Gervasi, M.D., Enrico Sebastiani, M.D., Alessandro Spicuzza, M.D. 
Arthroscopy Techniques 
Volume 6, Issue 1, Pages e219-e225 (February 2017)
DOI: /j.eats
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

2. Fig 1
Patient in lateral decubitus, left shoulder. The 3 portals held by a cannula are visible: posterior, anterosuperior, and midglenoid. The anterosuperior portal is mainly used for intra-articular viewing during the procedure.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

3. Fig 2
Patient in lateral decubitus, left shoulder, posterior viewing of the left shoulder. A posterolateral portal (dermographic pen) can be used for a better anchor placement in the inferior portion of the glenoid bone (6 o'clock). A red arrow marks the standard posterior portal.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

4. Fig 3
Patient in lateral decubitus, left shoulder, camera in the anterosuperior portal. Capsuloligamentous structures already detached from the subequatorial portion of the glenoid bone. The tool lifts the disconnected medial margin of the capsule and shows the decorticated glenoid neck.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

5. Fig 4
Patient in lateral decubitus, left shoulder, camera in the anterosuperior portal. Capsulolabroplasty is performed using double-loaded all-suture anchors. Anchor threads at the 6 o'clock position already passed through the capsular tissue; using a shuttle technique, we are working in the posteroinferior quadrant, with the second anchor seated at the 4.30 position. In this phase, a South-North shift of the capsular tissue needs to be obtained; therefore, the tool must emerge distally from the anchor.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

6. Fig 5
Patient in lateral decubitus, left shoulder, camera in the anterosuperior portal. The capsulolabroplasty is finished, the capsuloligamentous structures are retensioned, and a new glenoid labrum (called “bumper”) is reconstructed.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

7. Fig 6
The membrane is folded to assume a cylindrical shape. Two surgical clamps fix the membrane at the extremities. To keep the shape during suturing and ease the needle passage, straight 18-gauge needles pass through the folded graft. All needles have to be inserted in the same direction.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

8. Fig 7
The Vicryl No.1 (Ethicon, Somerville, NJ), tied to form a loop, is inserted in an eyed needle. Passing through the straight needles, the eyed needle pierces the graft and the suture thread along with it. The same procedure is to be performed with further needles, managing the suture with a SpeedWhip technique.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

9. Fig 8
A resorbable thread keeps the cylindrical shape of the graft. Three LabralTapes (Arhtrex, Naples, FL) pass through the graft at both ends and in the center. The free limbs of each LabralTape come out of the same side of the graft to shape a “U.” The central LabralTape has a different color to ease suture management within the articulation. We recommend tying together the loose ends of each LabralTape. The 2 LabralTapes at the extremities are used to anchor the graft to the anterior and to the posterior margins of the glenoid. The central LabralTape is used to anchor the graft at the 6 o'clock position. The posterior LabralTape is used to pull the graft inside the joint.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

10. Fig 9
One of the LabralTapes at the extremity of the graft is inserted into the articulation through the midglenoid portal and retrieved from the posterior one. Applying traction to this LabralTape, the graft is pulled into the joint through the midglenoid portal.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

11. Fig 10
Patient in lateral decubitus, left shoulder, camera in the anteroposterior portal. Once a hole has been made at the 6 o'clock position, the central LabralTape (the one differently colored) is anchored to the glenoid with a knotless anchor through the midglenoid portal.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

12. Fig 11
Patient in lateral decubitus, left shoulder, camera in the anteroposterior portal. The graft is anchored to the posterior margin of the glenoid with a knotless anchor (red arrow) through the posterior portal.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

13. Fig 12
Patient in lateral decubitus, left shoulder, camera in the anteroposterior portal. The graft made of resorbable surgical mesh derived from porcine skin is anchored to the glenoid rim along the entire subequatorial region.
Arthroscopy Techniques 2017 6, e219-e225DOI: ( /j.eats )
Copyright © 2016 Arthroscopy Association of North America Terms and Conditions