title: Inferior suture anchor placement during arthroscopic Bankart repair: influence of portal placement and curved drill guide.
abstract: BACKGROUND
  During arthroscopic Bankart repair, inferior anchor placement is critical to a successful outcome. Low anterior anchors may be placed with a standard straight guide via midglenoid portal, with a straight guide with trans-subscapularis placement, or with curved guide systems. Purpose/
  
  
  OBJECTIVE
  To evaluate glenoid suture anchor trajectory, position, and biomechanical performance as a function of portal location and insertion technique. It is hypothesized that a trans-subscapularis portal or curved guide will improve anchor position, decrease risk of opposite cortex breach, and confer improved biomechanical properties.
  
  
  METHODS
  Controlled laboratory study.
  
  
  METHODS
  Thirty cadaveric shoulders were randomized to 1 of 3 groups: straight guide, midglenoid portal (MG); straight guide, trans-subscapularis portal (TS); and curved guide, midglenoid portal (CG). Three BioRaptor PK 2.3-mm anchors were inserted arthroscopically, with an anchor placed at 3, 5, and 7 o'clock. Specimens were dissected with any anchor perforation of the opposite cortex noted. An "en face" image was used to evaluate actual anchor position on a clockface scale. Each suture anchor underwent cyclic loading (10-60 N, 250 cycles), followed by a load-to-failure test (12.5 mm/s). Fisher exact test and mixed effects regression modeling were used to compare outcomes among groups.
  
  
  RESULTS
  Anchor placement deviated from the desired position by 9.9° ± 11.4° in MG specimens, 11.1° ± 13.8° in TS, and 13.1° ± 14.5° in CG. After dissection, opposite cortex perforation at 5 o'clock occurred in 50% of MG anchors, 0% of TS, and 40% of CG. Of the 90 anchors tested, 17 (19%) failed during cyclic loading, with a similar failure rate across groups (P = .816). The maximum load was significantly higher for the 3-o'clock anchors when compared with the 5-o'clock anchors, regardless of portal or guide (P = .021). For the 5-o'clock position, there were significantly fewer "out" anchors in the TS group versus the CG or MG group (P = .038). There was no statistically significant difference in maximum load among groups at 5 o'clock.
  
  
  CONCLUSIONS
  Accuracy in suture anchor placement during arthroscopic Bankart repair can vary depending on both portal used and desired position of anchor. The results of the current study indicate that there was no difference in ultimate load to failure among anchors inserted via a midglenoid straight guide, midglenoid curved guide, or percutaneous trans-subscapularis approach. However, midglenoid portal anchors drilled with a straight or curved guide and placed at the 5-o'clock position had significant increased risk of opposite cortex perforation compared with trans-subscapularis percutaneous insertion, with no apparent biomechanical detriment.
  
  
  CONCLUSIONS
  The findings from this study will facilitate improved understanding of risks and benefits of several techniques for arthroscopic shoulder instability treatment with regard to suture anchor fixation.
authors.affiliation: Rachel M. Frank, Department of Orthopaedic Surgery, Rush University Medical Center, 1611 West Harrison Street, Suite 200, Chicago, IL 60612, USA. rmfrank3@gmail.com.
authors.forename: Rachel M
authors.initials: RM
authors.lastname: Frank
authors.forename: Nathan A
authors.initials: NA
authors.lastname: Mall
authors.forename: Deepti
authors.initials: D
authors.lastname: Gupta
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Shewman
authors.forename: Vincent M
authors.initials: VM
authors.lastname: Wang
authors.forename: Anthony A
authors.initials: AA
authors.lastname: Romeo
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Cole
authors.forename: Bernard R
authors.initials: BR
authors.lastname: Bach
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Provencher
authors.forename: Nikhil N
authors.initials: NN
authors.lastname: Verma
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001182:Arthroscopy / Q000379:methods*; D002102:Cadaver; D002358:Cartilage, Articular / Q000293:injuries / Q000601:surgery*; D005260:Female; D061165:Glenoid Cavity / Q000293:injuries / Q000601:surgery*; D006801:Humans; D008297:Male; D008422:Materials Testing; D008875:Middle Aged; D011897:Random Allocation; D013314:Stress, Mechanical; D053441:Suture Anchors
keywords: biomechanical; curved guide; glenoid portal; instability; percutaneous