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