arthroscopic bankart repairs final

8/7/2019 Arthroscopic Bankart Repairs Final

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ARTHROSCOPIC BANKART

REPAIR

T. Andrew Israel, MDLuther Midelfort Orthopaedic &

Sports Medicine Center


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ARTHROSCOPIC BANKART

REPAIR Historical Considerations

Current Understandings Surgical Goals

Advantages of Arthroscopic vs Open

Selection Criteria-preop & intraop Surgical Technique

Results


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HISTORICAL

CONSIDERATIONS

Traditionally, open Bankart gold

standard with recurrence


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CURRENT

UNDERSTANDINGS

Firm appreciation spectrum of instability

and range of pathology Better teaching of basic arthrosopic

techniques

Appreciation of the value of arthroscopyas outpatient surgical technique

Improved technical skills


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SURGICAL GOALS

Anatomic reconstruction

Reconstruction which approximates anopen repair

Ability to manage Bankart lesion and

capsular laxity Immediate strength of repair


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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


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PREOPERATIVE

SELECTION CRITERIA

Traumatic instability(subluxation or

dislocation)

Minimal bony lesion(s)

Discrete Bankart lesion

No generalized ligamentous laxity


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INTRAOPERATIVE

SELECTION CRITERIAOPTIMAL FACTORS

Discrete Bankart lesion Robust capsuloligamentous tissue

No Bony Bankart lesion

No significant loss of articularsurface(glenoid or humeral head)


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INTRAOPERATIVE

SELECTION CRITERTAMITIGATING FACTORS

Capsular laxity

ALPSA(Anterior Labral Periosteal Sleeve

Avulsion Injury)

Bony Bankart lesion


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SURGICAL TECHNIQUE

Position

Portal placement

Identify pathology Mobilize capsulolabral tissue

Glenoid preparation

Anchor placement Suture retrieval

Knot tying


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POSITION

Lateral decubitus Allows for traction

Improved exposure to glenohumeral

joint


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PORTAL PLACEMENT

Standard posterior portal

Antero-superior scope portal Antero-inferior working portal

Avoid crowding of anterior portals

Clear cannulas allow visualization ofsutures and anchors


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IDENTIFY PATHOLOGY

Bankart lesion

Quality of capsulolabral tissue Concomitant SLAP lesion

Rotator cuff injuries

Injury to articular surfaces


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MOBILIZE

CAPSULOLABRAL TISSUE

Arthroscopic elevators Mitek VAPR

Strip off capsulolabral sleeve to muscle

of subscapularis


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GLENOID PREPARATION

Decorticate juxta-articular scapular neck Curette

Rasp

Shaver


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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 nextanchor placement


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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


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KNOT TYING

Perfect knots Perfect knots

Flawlessly perfect knots


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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%)


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CASE PRESENTATION


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CASE J.H.

24 male RHD plumber

Traumatic left anterior shoulderdislocation @ age 15 during football

Rx nonoperatively with sling, PT, etc.

Recurrent dislocations duringrecreational softball @ age 23 and 24


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PHYSICAL EXAM

AROM 175/175, 65/75, T12/T10

5/5 power abduction & external rotation 2+ anterior/inferior laxity with endpoint

Positive Jobes anterior

apprehension/relocation test Negative sulcus sign


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SHOULDER ANATOMY


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SURGERY


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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

arthroscopic bankart repairs final

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