Transcript Arthroscopic Shoulder Repair

ARTHROSCOPIC BANKART
REPAIR
T. Andrew Israel, MD
Luther Midelfort Orthopaedic &
Sports Medicine Center
ARTHROSCOPIC BANKART
REPAIR
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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
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Faster(for some surgeons)
Less pain for patient
Better cosmesis
Better ROM(not shown by some studies)
Ability to manage comorbid pathologySLAP, 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
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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
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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
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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
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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
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Decorticate juxta-articular scapular neck
Curette
Rasp
Shaver
ANCHOR PLACEMENT
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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
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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
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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