ARTHROSCOPIC BANKART REPAIR

T. Andrew Israel, MDLuther 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

• Results

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

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

SURGICAL GOALS

• Anatomic reconstruction

• Reconstruction which approximates an open repair

• Ability to manage Bankart lesion and capsular laxity

• Immediate strength of repair

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

PREOPERATIVE SELECTION CRITERIA

• Traumatic instability(subluxation or dislocation)

• Minimal bony lesion(s)

• Discrete Bankart lesion

• No generalized ligamentous laxity

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)

INTRAOPERATIVE SELECTION CRITERTA

MITIGATING FACTORS

• Capsular laxity

• ALPSA(Anterior Labral Periosteal Sleeve Avulsion Injury)

• Bony Bankart lesion

SURGICAL TECHNIQUE

• Position

• Portal placement

• Identify pathology

• Mobilize capsulolabral tissue

• Glenoid preparation

• Anchor placement

• Suture retrieval

• Knot tying

POSITION

• Lateral decubitus

• Allows for traction

• Improved exposure to glenohumeral joint

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

IDENTIFY PATHOLOGY

• Bankart lesion

• Quality of capsulolabral tissue

• Concomitant SLAP lesion

• Rotator cuff injuries

• Injury to articular surfaces

MOBILIZE CAPSULOLABRAL TISSUE

• Arthroscopic elevators

• Mitek VAPR

• Strip off capsulolabral sleeve to muscle of subscapularis

GLENOID PREPARATION

• Decorticate juxta-articular scapular neck

• Curette

• Rasp

• Shaver

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

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

KNOT TYING

• Perfect knots

• Perfect knots

• Flawlessly perfect knots

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%)

CASE PRESENTATION

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

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

SHOULDER ANATOMY

SURGERY

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