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ARTHROSCOPIC BANKART REPAIR

ARTHROSCOPIC BANKART REPAIR. T. Andrew Israel, MD Luther Midelfort Orthopaedic & Sports Medicine Center. ARTHROSCOPIC BANKART REPAIR. Historical Considerations Current Understandings Surgical Goals Advantages of Arthroscopic vs Open Selection Criteria- preop & intraop Surgical Technique

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ARTHROSCOPIC BANKART REPAIR

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  1. ARTHROSCOPIC BANKART REPAIR T. Andrew Israel, MD Luther Midelfort Orthopaedic & Sports Medicine Center

  2. ARTHROSCOPIC BANKART REPAIR • Historical Considerations • Current Understandings • Surgical Goals • Advantages of Arthroscopic vs Open • Selection Criteria-preop & intraop • Surgical Technique • Results

  3. HISTORICAL CONSIDERATIONS • Traditionally, open Bankart gold standard with recurrence <5% • Arthroscopic repair initially presented with great enthusiasm by developers but results could not be duplicated • Limited understanding of pathology • Poor patient selection • Technically demanding techniques

  4. CURRENT UNDERSTANDINGS • Firm appreciation spectrum of instability and range of pathology • Better teaching of basic arthrosopic techniques • Appreciation of the value of arthroscopy as outpatient surgical technique • Improved technical skills

  5. SURGICAL GOALS • Anatomic reconstruction • Reconstruction which approximates an open repair • Ability to manage Bankart lesion and capsular laxity • Immediate strength of repair

  6. ADVANTAGES OF ARTHROSCOPIC VS OPEN • Faster(for some surgeons) • Less pain for patient • Better cosmesis • Better ROM(not shown by some studies) • Ability to manage comorbid pathology-SLAP, OA, RCT • Less expensive than open repair

  7. PREOPERATIVE SELECTION CRITERIA • Traumatic instability(subluxation or dislocation) • Minimal bony lesion(s) • Discrete Bankart lesion • No generalized ligamentous laxity

  8. INTRAOPERATIVE SELECTION CRITERIA OPTIMAL FACTORS • Discrete Bankart lesion • Robust capsuloligamentous tissue • No Bony Bankart lesion • No significant loss of articular surface(glenoid or humeral head)

  9. INTRAOPERATIVE SELECTION CRITERTA MITIGATING FACTORS • Capsular laxity • ALPSA(Anterior Labral Periosteal Sleeve Avulsion Injury) • Bony Bankart lesion

  10. SURGICAL TECHNIQUE • Position • Portal placement • Identify pathology • Mobilize capsulolabral tissue • Glenoid preparation • Anchor placement • Suture retrieval • Knot tying

  11. POSITION • Lateral decubitus • Allows for traction • Improved exposure to glenohumeral joint

  12. PORTAL PLACEMENT • Standard posterior portal • Antero-superior scope portal • Antero-inferior working portal • Avoid crowding of anterior portals • Clear cannulas allow visualization of sutures and anchors

  13. IDENTIFY PATHOLOGY • Bankart lesion • Quality of capsulolabral tissue • Concomitant SLAP lesion • Rotator cuff injuries • Injury to articular surfaces

  14. MOBILIZE CAPSULOLABRAL TISSUE • Arthroscopic elevators • Mitek VAPR • Strip off capsulolabral sleeve to muscle of subscapularis

  15. GLENOID PREPARATION • Decorticate juxta-articular scapular neck • Curette • Rasp • Shaver

  16. ANCHOR PLACEMENT • Place first anchor as low as possible • At or on the articular cartilage margin • Metal or biodegradable • Prefer minimum of 3 anchors • Pass sutures and tie knots before next anchor placement

  17. SUTURE RETRIEVAL • Many options • Devices which perforate capsule and retrieve the suture • Devices which shuttle the suture through the tissue • Prefer suture relay technique as it reduces trauma to suture & allows for easier shift from inferior to superior

  18. KNOT TYING • Perfect knots • Perfect knots • Flawlessly perfect knots

  19. RESULTS Gartsman, JBJS, 2000 • 53 arthroscopic Bankart repairs • Mean age 32 yrs • 44 males & 9 females • 33 month follow-up • 34/38 athletes return to sport • 4/53 recurrent instability(7.5%)

  20. CASE PRESENTATION

  21. CASE J.H. • 24 male RHD plumber • Traumatic left anterior shoulder dislocation @ age 15 during football • Rx nonoperatively with sling, PT, etc. • Recurrent dislocations during recreational softball @ age 23 and 24

  22. PHYSICAL EXAM • AROM 175/175, 65/75, T12/T10 • 5/5 power abduction & external rotation • 2+ anterior/inferior laxity with endpoint • Positive Jobe’s anterior apprehension/relocation test • Negative sulcus sign

  23. SHOULDER ANATOMY

  24. SURGERY

  25. SUMMARY • Arthroscopic techniques here to stay • Pt expectations & economic pressures driving application of these techniques • % performed arthroscopically will increase over time(more resident & fellow education) • Techniques & implants/devices will improve over time

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