ARTHROSCOPIC BANKART REPAIR T. Andrew Israel, MD Luther Midelfort Orthopaedic & Sports Medicine...
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Transcript of ARTHROSCOPIC BANKART REPAIR T. Andrew Israel, MD Luther Midelfort Orthopaedic & Sports Medicine...
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