Recurrent shoulder dislocations are an important health problem that affects the young adult population and creates serious limitations in their life. Anterior instability is a broad spectrum ranging from a labral lesion involving purely soft tissue injury to instability with bone loss. The separation of the anteroinferior labroligamentous complex from the glenoid together with the periosteum, which often accompanies traumatic first dislocations, is called the classical "Bankart lesion". Before surgery, the reason behind the instability should be clearly revealed. The osseous integrity of the glenoid, the labral-ligamentous complex that provides the centralization of the humeral head, the muscle strength that presses the humeral head to the glenoid, the joint surface and its integrity should be evaluated and the problem should be determined correctly, and the correct treatment and prevention of the problems after the treatment should be ensured.
Nowadays, minimally invasive techniques are becoming widespread in many areas of orthopedics. Shoulder arthroscopy is a treatment proven to be as successful as open surgery and has many advantages over open surgery, such as early movement, less pain, early discharge, less scar tissue (7-9). The learning curve for arthroscopic treatments of the shoulder is long. The main problems experienced in the anterior double portal technique are the close placement of the cannulas, the loss of time to open the second cannula, the tangling and knotting of the sutures during suture transport. . Compared to the anterior double portal technique, the anterior single portal technique, which is thought to facilitate the surgical technique, has recently been preferred by many shoulder surgeons. In our study, we aimed to show that in arthroscopic anterior stabilization, which is as successful as open surgery, anterior single portal repair technique using “birdbeak” is as successful and reliable as the classical anterior double portal technique.
There are a limited number of studies in the literature comparing anterior single portal and anterior double portal techniques. In recent studies, tests such as Constant Shoulder Score, RWS and OSIS were evaluated in the anterior single portal group, and no statistical difference was found in the postoperative test scores between the two groups. (7,12,13).
In our study, we evaluated preoperative and postoperative SST, RWS and OSIS test scores. When the test results were evaluated, the results of the anterior single portal technique were found to be similar to the anterior double portal technique in the literature. From this point of view, the anterior single portal technique was thought to be as reliable as the anterior double portal technique.
Re-dislocation is the most undesirable complication after surgical treatment in patients with anterior shoulder instability. Especially in patients with multiple dislocations, bone defects reduce the success of the surgery. As a result of the 3-year study by Boileau et al., a 15% risk of re-dislocation was observed after arthroscopic repair, another study conducted by Gartsman et al., the risk of re-dislocation was observed as 8%. (4,14). In other studies, it was observed that the risk of instability increased as a result of weakening of the rotator interval. (15,16). It can be thought that the injury in the rotator interval with the anterior double portal technique increases the risk of dislocation since it is less injured in the single portal. In our study, no re-dislocation was observed although apprehension test was positive in 1 patient who had no additional problems observed in the follow-ups.
The most technically challenging part of arthroscopic bankart repair with the anterior single portal is to properly and perfectly position the anterior portal to reach the lowest part of the torn labrum (11). In some studies, the use of transscapular portals has been suggested to have a better view for the lower part of the lesion during arthroscopic anterior stabilization, but risks such as proximity to the axillary artery and nerve, musculocutaneous nerve and cephalic vein should be in mind (17,18). Failure to place anchors in a good position can result in failure of repair, recurrence of instability, and high risk of recurrent dislocations (19). Therefore, in our study, the anterior single portal was placed just above the subscapularis muscle. With this portal placement, the lowest anchor can be placed as close to the 5 o'clock position as possible and stabilization of the glenoid labrum can be achieved (11).
Surgical intervention after the first dislocation still remains a matter of debate. In a single-blind study, a comparison was made between the patient group who underwent three weeks of immobilization and then rehabilitation treatment in case of acute first dislocation, and the patient groups who underwent arthroscopic anterior stabilization within the first four weeks; It was stated that the shoulder stability of the patients who underwent arthroscopic intervention in the first four weeks was better than the patients followed by immobilization, but the shoulder range of motion was similar in both groups. (20). None of the patients in our study underwent surgical intervention within a month after the first dislocation.
The use of “Birdbeak” has been described in arthroscopic procedures for repair of labral tears, rotator cuff tears, spinoglenoid notch cyst and SLAP (21,22). The “BirdBeak 45o angled suture threader” (Arthrex, Naples, Italy) has an extremely sharp tip to easily penetrate soft tissue, a rigid structure that resists bending during tissue shifting, and a handle that allows easy operation from any hand position. Similar to other suture-permeable and carrier techniques, care should be taken to ensure that the number of penetrations is low and that no labral defect is created in labral repair with the “Birdbeak suture threader”. The use of a “suture lasso” (Arthrex, Naples, FL) has been described previously to capture anchor threads and pass threads through the labrum, following placement of anchors for labrum repair from the anterior single portal (11). The use of knotless anchors has also been reported in the literature due to its advantages such as ease of use and no knots in the joint. (6). In our study, “Birdbeak” was used for anterior stabilization and labrum repair. A similar study using “Birdbeak” has not been observed in the literature.