John D. Kelly IV, MD , 2025-04-17 17:45:00
April 17, 2025
5 min read
The surgical treatment of the disabled throwing shoulder has rapidly evolved. Thanks to many mentors, especially W. Ben Kibler, MD, FACSM, and Thay Q. Lee, PhD, I am eager to share the insights I have gained during the last 3 decades.
Before we embrace surgical steps, some basic truths regarding the biceps/superior labrum complex that have served me well are worthy of mention.
Figure 1. The portal placement is shown.
Source: John D. Kelly IV, MD
First, labral changes on MRI are ubiquitous in the throwing athlete. Several anatomic variants exist, including the Buford complex, sublabral foramen and meniscoid labrum, which can manifest as abnormal imaging findings. In an effort not to become a “SLAPaholic,” one must employ imaging findings as confirmatory, not as a justification for surgery. I trust the patient’s history and positive examination findings (especially the dynamic labral shear test) should be present before surgery is entertained.
Figure 2. The inferior extension of superior labral tear (clinically significant labral injury [CSLI] lesion) is shown.
Source: John D. Kelly IV, MD
Second, superior labral stretching may serve as an adaptive development to the high velocity pitcher. The superior labrum is natively mobile and to surgically rigidly coapt this structure to the glenoid will result in stiffness and impaired kinematics. In collaboration with Lee, we have shown labral fixation immediately posterior to the biceps causes excessive humeral head translation in follow through as well as increased glenoid contact stresses.
Figure 3. The Kim lesion (post-inferior labrum) is shown.
Source: John D. Kelly IV, MD
Third, thanks to the work of Gregory I. Bain, MBBS (Adel), FRACS, FA(Ortho)A, PhD, and others, we now know that the mobile superior labrum becomes rigidly fixed and closely applied to the glenoid at approximately the 10 o’clock position in the right shoulder. Kibler has termed this region the “rip stop” area, and tears involving this region and extending inferiorly create adverse mechanical consequences. Tears involving the rip stop region and extending inferiorly are what Kibler has termed the clinically significant labral injury (CSLI) lesion. Thus, lesions originating at the approximately 10 o’clock position with inferior extension are precisely what require surgical repair.
Figure 4. The CSLI lesion is shown.
Source: John D. Kelly IV, MD
Lastly, the biceps tendon is an important glenohumeral stabilizer and humeral head depressor. Bain has elegantly demonstrated that biceps contraction coapts the mobile superior labrum against the humeral head in addition to dynamizing the superior glenohumeral ligament and middle glenohumeral ligament. In addition, Lee has illustrated that bicep contraction serves as a material humeral head centering device — preventing excessive posterior humeral head translation in late cocking and restricting anterior translation in follow through.
Surgical procedure
Although I favor the lateral decubitus position, labral surgery can be performed well in the beach chair position. I have found the lateral position affords easier access to the posterior inferior labrum, where the CSLI lesion resides.
John D. Kelly IV
After a standard posterior portal is established, I immediately create the anterosuperior lateral (ASL) portal, located just off the leading edge of the acromion (Figure 1). This portal is created sharply with an #11 blade following a spinal needle.
Figure 5. The posterior inferior tear extension (CSLI) is shown.
Source: John D. Kelly IV, MD
Next, a standard anterior portal is established superior to the subscapularis. This portal is placed more medially than a standard Bankart portal to afford working access to the posterior glenoid.
The diagnostic scope begins, and probing of the superior labrum is paramount. A merely stretched superior labrum is simply debrided. Conversely, a complete separation of the biceps labral complex will need surgical repair and invariably extends to the rip stop region.
Figure 6. The drill onto glenoid is shown.
Source: John D. Kelly IV, MD
We then switch to the ASL portal, which creates a true “room with a view” of the superior and posterior labral complex. At this point we carefully probe the labrum and look for inferior extension (Figure 2). We are careful to look for a concealed Kim lesion or posterior inferior labral tear (Figure 3). The Kim lesion serves as an anchoring point for the posterior band of the inferior glenohumeral ligament and must be addressed in the throwing athlete to restore integrity of the entire inferior glenohumeral ligament complex.
Figure 7. The percutaneous suture shuttling is shown.
Source: John D. Kelly IV, MD
Once the CSLI lesion is identified, (Figures 4 and 5) while viewing from the ASL portal, we prepare the glenoid surface with an elevator from the anterior portal (Video 1). Alternatively, viewing from the straight anterior portal allows excellent working access from the ASL portal. Once the labrum is liberated, we prepare the glenoid with a shaver, not a burr, as we believe any loss of glenoid bone is consequential. Patrick St. Pierre, MD, has shown that excessive recipient bed preparation may not be necessary and calls into question the need for aggressive bony bed treatment.
Figure 8. The Port of Wilmington percutaneous anchor is shown.
Source: John D. Kelly IV, MD
We begin anchor insertion inferiorly to proximally. Anchors are placed percutaneously to avert damage to the posterior cuff. We employ a posterolateral puncture to place our 7 o’clock anchor (Figure 6). A sharp tipped drill guide follows the path of a spinal needle to afford an oblique angle to the glenoid. Anchors are placed onto the glenoid surface to mimic native anatomy. We employ a percutaneous crescent type shuttling device using two passes to create a horizontal mattress configuration (Figure 7). We believe a horizontal mattress knotted suture creates optimal bumper restoration and ensures that no suture is exposed onto the glenoid surface.
Figure 9. The Neviaser portal suture shuttling is shown.
Source: John D. Kelly IV, MD
As we proceed up to the rip stop region (10 o’clock), we utilize a port of Wilmington percutaneous stab incision located approximately 1 cm posterior and 1 cm lateral to the posterior lateral corner of the acromion (Figure 1). Care is taken not to place this anchor within 1 cm of the biceps insertion for fear of “hog tying” the biceps and introducing excessive restraint to the natively mobile superior biceps labral complex (Figure 8). We have found that the Neviaser portal is extremely helpful in shuttling sutures in this area. A simple spinal needle is used to pierce the labrum just superior to the anchor (Figure 9). The shuttling material is retrieved from the posterior portal, and knot tying is executed from this portal as well.
Usually, two to three anchors suffice, and we are careful not to capture the capsule when shuttling sutures.
Success is realized when the rip stop region of labral attachment and bumper configuration are restored (Figure 10; Video 2).
Figure 10. The completed CLSI repair is shown.
Source: John D. Kelly IV, MD
Once the surgery is completed, we immobilize our throwers for 5 weeks in an abduction sling, with focus on early elbow, wrist and scapular exercises. We begin physical therapy at 6 weeks and generally allow light tossing at 3.5 months, with return to full throwing generally at the 6-month mark.
Pearls
- Capture only labral tissue, not capsule tissue, with shuttling devices to not over constrain the joint.
- In the presence of a Bankart lesion, we repair the anterior labrum first. Due to the circle concept, posterior labral fixation may impede access to the generally less accessible anterior labrum.
- Avoid prominent knots and sutures at all costs as chondral wear is a likely result.
- If you encounter a patient who has had prior labral surgery with multiple (four or more) anchors, they are likely over constrained and may have suture arthropathy.
- Address the kinetic chain, especially shoulder loss of motion, scapula dyskinesis, core weakness, biceps, latissimus, hip, spine and quadriceps tightness — otherwise risk for reinjury will be present.
- A prior failed labral repair may have been due to labral over constraint, failure to recognize the CSLI lesion, neglect of kinetic chain, suture/knot prominence or poor indications. The superior labrum is naturally mobile.
References:
For more information:
John D. Kelly IV, MD, the director of shoulder sports and director of Penn Throwing Lab at the Penn Perelman School of Medicine, can be reached at john.kelly@pennmedicine.upenn.edu.