Post on 08-Apr-2018
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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