arthroscopic vs. open bankart repair where are we today? bill wiley orv october 24, 2002
Post on 29-Dec-2015
223 Views
Preview:
TRANSCRIPT
Arthroscopic vs. Open Bankart Repair
Where are we Today?Bill Wiley ORV October 24, 2002
History
• Traumatic
• Documented direction
• Position of Arm at time of dislocation– Abduction and External Rotation
• Young male
• First time vs. Recurrent
• Voluntary
Physical Exam
Physical Exam• Neurologic Status of Axillary Nerve
– Sensation– Motor
• ROM– Dominant Side has Increased ER– Pitchers have Increased ER
• Status of Rotator Cuff• Apprehension Sign• Relocation Test• Sulcus Sign > 2 cm
Physical Exam
• Load and Shift Test (Silliman & Hawkins)– Grade I – humeral rides up to edge of glenoid– Grade II – humeral head goes over glenoid but
reduces spontaneously– Grade III – humeral head stays dislocated
• Good to do in EUA on both shoulders
Physical Exam
• Beighton Hypermobility Score (9 possible)– DF 5th MCP >90 (each side 1)– Thumb to Volar Wrist (each side 1) – Hyperextend Elbow >10 (each side 1)– Hyperextend Knee >10 (each side 1)– Hands flat on Floor
Physical Exam
• Other Hypermobility Signs and Tests– Other Shoulder ER at 90 ABD >90– Finger DIP DF >60– Thumb MP Hyperext >90– Widened Scars– Marfanoid Habitus
Imaging Studies
• AP in scapular plane• Lateral (Axillary/Scapular Y)• Other Views:
– Stryker Notch– Hill Sachs View– West Point Axillary– Velpeau Axillary
Stryker Notch
Apical Oblique/Garth View
Imaging Studies
• CT Scan– Glenoid Deficiency– Humeral Head Deficiency
• MRI– With or W/O Gadolinium– Adducted and Abduction/Ext Rot.
History of Bankart Lesion
• Described by Perthes in 1906
• Bankart reported on 27 cases in 1923
Rowe Outcome Measure
• Stability 50 pts• Motion 20 pts• Function 30 pts
• Excellent 90 to 100• Good 75 to 89• Fair 51 to 74• Poor <50
Results of Open Bankart
• Rowe JBJS 1978– 145 patients– Avg F/U 6 yrs– 3.5% Recurrence– 69% Full ROM– 97% G/E Rowe Score
Results of Open Bankart
• Thomas, Matsen JBJS 1989– 39 shoulders– Avg F/U 5.5 yrs– 2.5% Recurrence (however 5% had symptoms)– ER @ 90 Deg 84 (range 43 to 108)– 97% G/E Rowe Score
Results of Open Bankart
• Thomas, Matsen JBJS 1989– Classic Article where described
• TUBS (Traumatic, Unidirectional, Bankart, Surgery)
• AMBRI (Atraumatic, multidirectional, bilateral, rehabilitation, inferior shift)
Results of Open Bankart
• Jobe AJSM 1991– 25 skilled athletes– Avg F/U 3.3 yrs– No Recurrence– 18/25 returned to competitive level– 8 pt’s had loss of ER (avg 12 deg)– 92% G/E Mod Rowe Score
Arthroscopic Grading
• Baker AJSM 1990 – 45 first time dislocations, Avg 21yoa – Group I (13%) – no labral lesion, capsular tear– Group II (24%) – partial labral detachment
w/capsular tear– Group III (62%) – complete labral detachment
w/capsular tear
Other Arthroscopic Findings
• Wolf Arthroscopy 1995 – 9.3% HAGL
Other Arthroscopic Findings
• Neviaser 1993 – ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion)
Other Arthroscopic Findings
• GARD Lesion – Glenoid Articular Rim Disruption. Posterior labral tear in association w/osseous defect of posterior glenoid (Chan 1998)
Other Arthroscopic Findings
• GLAD Lesion – Glenolabral Articular Disruption. Tear of anteroinferior labrum w/glenoid articular cartilage injury. No instability on exam, MoI – forced ADD from ABD/ER (Neviaser 1993)
• Bennett Lesion – Posteroinferior ossification/calcification associated with Posterior labral tear (1941)
Other Arthroscopic Findings
• SLAC Lesion – Superior Labrum Anterior Cuff lesion (Savoie OCNA 2001)– Injury to the Superior Anterior glenoid labrum
that involves the insertion of the SGHL and the anterior portion of the biceps tendon
– Allows the undersurface of the supraspinatus tendon to contact the AS glenoid and cause a tear
Considerations
• Drive Through Sign (92% Sens, 38% Spec, McFarland 2001)
• Size of Hill-Sachs Lesion• Associated Rotator Cuff
Tear• Capsular Redundancy• Other Fractures
Arthroscopic Bankart
• Gartsman JBJS 2000– Prospective Outcome study– 60 patients– 53 pt’s (88%) Follow-up– Avg Age 32 yrs– Avg F/U 33 months– Single Surgeon
Arthroscopic Bankart
• Gartsman JBJS 2000– Stepwise Technique:
• Repair Labral tears (48)
• Capsular Tensioning – to prevent translation over 25% of glenoid:
– Adv Capsule to labrum/glenoid (46)
• Rotator Interval Closure (14)
• Thermal Capsulorrhaphy - Laser (48)
Arthroscopic Bankart
• Gartsman JBJS 2000– Suture anchors used in 52 patients (1 to 5)– Wide range of suture anchor types– Currently using metallic screw in anchor
Arthroscopic Bankart
• Gartsman JBJS 2000– Results
• Rowe Score improved from 11 to 92• 92% G/E Rowe Score• 9% w/>5 degree loss of ER• 8% Recurrent Instability
Arthroscopic Bankart
• Noojin, Savoie Orthop Today 2000– Prospective Consecutive Series– 35 patients– 2 Surgeons– Mean Age of 27– Minimum 2 yr F/U (24-36 mo.)
Arthroscopic Bankart
• Noojin, Savoie Orthop Today 2000– Technique:
• Used a minimum of 3 Panalok Anchors with single loaded Panacryl Suture
• Also Closes the Rotator Interval
Arthroscopic Bankart
• Noojin, Savoie Orthop Today 2000– Results
• 170 Degrees FE• ER @ 90 avg 110 Degrees• Avg Rowe Score of 93• 1 (3%) Redislocation
Arthroscopic Bankart
• Thal CORR 2001– Prospective Outcome Evaluation– Using the Knotless metallic GII-like suture
anchor (now Mitek has bioabsorbable)– 27 patients– Avg Age 28 yrs– Avg F/U 29 mo– Single Surgeon
Arthroscopic Bankart
• Thal CORR 2001
Arthroscopic Bankart
• Thal CORR 2001
Arthroscopic Bankart
• Thal CORR 2001– Results
• 5 patients had SLAP repair• All satisfied• 1 (4%) pt traumatic recurrent dislocation• 2 (7%) pts 10 deg loss of ER at 90 deg
Comparison Studies
• Cole, Warner JBJS 2000– Prospective Nonrandomized evaluation of their
selection criteria– 59 patients– 94% Followup– Selection Criteria to go Open Shift:
• EUA: 2+ or greater ant & inf translation• Arthroscopic Exam: capsular rupture or thinning,
combined capsular laxity w/Bankart lesion
Comparison Studies
• Cole, Warner JBJS 2000
Arthr Open
No. Pt’s 37 22
Age 28 27
F/U yrs 4.4 4.5
Comparison Studies
• Cole, Warner JBJS 2000– Arthroscopic Technique: 2 or 3 suretac– Open Technique: bankarts repaired and then
anteroinferior humeral capsular shift (do not mention how bankarts were repaired)
Comparison Studies
• Cole, Warner JBJS 2000
Arthr Open
Recurrence 16% 9%
Mean Rowe 83 82
G/E Rowe 76% 77%
ER @ 90 -6 deg -8 deg
None of these were statistically different
Comparison Studies
• Karlsson AJSM 2001– Prospective, Nonrandomized based on patient
choice– 3 Surgeons– 119 Shoulders– 91% Followup– Excluded if no bankart lesion and converted to
open capsular shift
Comparison Studies
• Karlsson AJSM 2001
Arthr Open
No. Pt’s 60 48
Age 26 27
F/U yrs 2.4 3
Comparison Studies
• Karlsson AJSM 2001– Arthroscopic Technique: 2 or 3 Suretac– Open Technique: 2-4 TAG (Acufex – 24 pt’s)
or Mitek (29 pt’s) suture anchors, using modified Rowe Technique
Comparison Studies
• Karlsson AJSM 2001
Arthr Open
Recur. Inst. 15% 10%
Mean Rowe* 93 89
ER @ 90* 90 deg 80 deg
*Statistically Different
Comparison Studies• Sperber, Karlsson JSES 2001
– Prospective, Randomized Multicenter Study
– 7 Surgeons
– 56 patients
– Inclusion: >17 yoa, unilateral, recurrent anterior instability w/arthroscopically verified bankart lesion
– Exclusion: primary dislocation < 3 mo, bilateral instability, MDI, additional soft-tissue injuries
Comparison Studies
• Sperber, Karlsson JSES 2001
Arthr Open
No. Pt’s 30 26
Age 25 27.5
F/U yrs 2 2
Comparison Studies
• Sperber, Karlsson JSES 2001– Arthroscopic Technique: 1-3 Suretac
– Open Technique: 1-4 anchors by choice of the surgeon w/capsular shift as needed
Comparison Studies
• Sperber, Karlsson JSES 2001
Arthr Open
Recur. Inst. 23% 12%
Rowe – stable sh’s 100 95
Loss of ER 9 deg 10 deg
None of these were statistically different
Comparison Studies
• Kim Arthroscopy 2002– Retrospective Case Control Study– Early part did open, Later arthroscopic– 93 Shoulders– 96% available for F/U– 1 Surgeon– Only Study to compare arthroscopic and open
bankart repair using suture anchors in both
Comparison Studies
• Kim Arthroscopy 2002
Arthr Open
No. Pt’s 59 30
Age 25.3 25.2
F/U yrs 2.8 4.1
Comparison Studies
• Kim Arthroscopy 2002– Arthroscopic Technique: 3-6 mini-Revo screw
suture anchors, No. 2 ethibond– Open Technique: 2-3 Mitek suture anchors,
No. 2 ethibond
Comparison Studies
• Kim Arthroscopy 2002
Arthr Open
Recur. Inst. 3.4% 6.7%
Rowe 92.7 90.4*
Avg Loss of ER 4 deg 6 deg
>10 deg loss ER 7% 23%*
*p<0.05
First Time Dislocators
• Reasons for Arthroscopic Tx– Up to 90% Recurrence in those under 21– Address associated pathology– Repair Tissue while still in good condition
First Time Dislocators
• Bottoni AJSM 2002– Prospective Randomized Trial– Army Population– 24 patients– 88% F/U– Min F/U 16 months
First Time Dislocators
• Bottoni AJSM 2002
Arthr Cons
No. Pt’s 9 12
Age 22 (19-26) 23(19-26)
F/U yrs 2.9 3.1
First Time Dislocators
• Bottoni AJSM 2002– Used suretacs– 2 tacks in 9, 3 in 1 patient– Return to Full Active duty by 4 months– Rehab same for both groups
First Time Dislocators
• Bottoni AJSM 2002
Arthr Cons
Recur. Inst. 11% 75%
SANE Score 88 57*
L’Insalata Score 94 73*
Loss of ER 4 deg 3 deg
*p<0.002
SANE Score (AJSM 1999)
• Single Assessment Numeric Evaluation– How would you rate your shoulder today as a
percentage of normal? (0 to 100% w/100% being normal)
– Correlated well w/Rowe and ASES shoulder scores
L’Insalata Score JBJS 1997
• Global Assessment 15 pts
• Pain 40 pts
• Daily Activities 20 pts
• Recreation/Athletic Activities 15 pts
• Work 10 pts
First Time Dislocators
• Bottoni AJSM 2002– 1 failure of arthroscopic tx underwent open
repair– 6 failures of the closed tx underwent open
repair
top related