Bankart Repair

1. Bankart Repair By: Abbie Mitchell, Brian Bartow, Jordan Anderson, & Tyler Pecha

2. BackgroundPathology/Etiology: • What is a Bankart Lesion? • A Bankart lesion is a traumatic detachment of the glenoid labrum . • Most common cause: Dislocation of the shoulder. • At the time of original injury, the humeral head is forced out anteriorly and inferiorly, first stretches the anterior capsule and the inferior glenoid ligament. • As a result of the traction from the inferior glenoid ligament, the fibrous labrum is pulled off from the anterior rim of the glenoid. • Seen in over 85% of cases after a traumatic anterior dislocation. • More common in younger (under 30 years old) individuals. • The inferior glenoid ligament is the most important stabilizer of the shoulder; The stretch of the ligament and the resulting Bankart lesion results in shoulder instability.

3. BackgroundAnatomy/Physiology:

4. BackgroundAnatomy/Physiology:

5. BackgroundProcedure: • When is the procedure performed? • Surgery is recommended with younger than middle age individuals who lead active lifestyles. • Biggest factor is chance for repeat dislocations. • Other factors: Patient’s pain, instability, lifestyle, and activities. • Approximate percentage for re-dislocation: • Under the age of 20 = 90% • Between 20-30 years old = 75% • Between 30-40 years old = 30%

6. BackgroundProcedure: • Traditionally, most orthopedic surgeons would not choose to operate on a patient after a first dislocation. Rather, after a brief period of immobilization, followed by physical therapy, the patient would gradually resume their normal activities. If the patient sustained a second, or recurrent, dislocation, then surgery was considered. • More recently, there is good scientific evidence to support early surgery, especially in young patients who are at a high risk for re-dislocation.

7. BackgroundProcedure: • Can be completed arthroscopically or via open surgical technique. • Involves reattachment and tightening of the labrum and ligaments of the shoulder. • Usually done using sutures and small bone anchors. • Surgeon will also smooth out rough edges of labrum.

8. BackgroundProcedure:

9. Examination • AROM – guarding, compensatory movements, scapular kinematics (delayed until active motion is allowed). • PROM – guarding, pain • check incision – color, temperature, healing process, signs of infection, bandaging • palpation • pain • swelling • neurological changes – temperature, sensation, weakness • mechanism of initial injury • medical/surgical/injury history • medication compliance • PLF, CLF • occupation, hobbies, recreational activities • living environment • patient goals

10. Examination:Tests/Measures for ROM • inter- and intra-rater agreement for 5 different methods of assessing shoulder range of motion in 6 directions: • visual estimation • inter: 0.57-0.70 • intra: 0.59-0.67 • goniometry • inter: 0.64-0.69 • intra: 0.53-0.65 • still photography • inter: 0.62-0.73 • intra: 0.56-0.61 • stand and reach • inter: 0.74 • intra: 0.49 • hand behind back reach • inter: 0.26-0.39 • intra: 0.14-0.39 • fair-good reliability found for all methods except hand behind the back reach (poor)

11. Evaluation • functional outcomes assessment • DASH Questionnaire • Shoulder Pain and Disability Index • University of Pennsylvania Shoulder Score • American Shoulder and Elbow Surgeons Shoulder Form • Rowe Shoulder Score • comparison of examination findings to expected presentations • constant re-evaluation of patient progress • use non-operative side as a “standard” for comparison as able (after precautions removed)

12. Signs & Symptoms • pain • swelling • guarding • catching • tenderness to palpation • compensatory movements (ex: shoulder hike) • poor scapular kinematics • apprehension

13. Differential Diagnosis • Bankart Lesion: • is an avulsion of the anteroinferior glenoid labrum at its attachment to inferior glenohumeral ligament (IGHL) complex; lesion is felt to result from anterior shoulder dislocation and is felt to be primary lesion in recurrent anterior instability. • Hill-Sachs lesion: • impression fracture of the humeral articular surface caused by translation of the humeral head over the glenoid rim. Found in 85% of anterior dislocations. If >25% of the articular surface is involved allograft or autograft bone graft to repair the defect is indicated

14. Differential Diagnosis • SLAP (superior labral anterior posterior tear) • Acquired Posterior Capsular Contracture in throwing athletes leads to high torsional and shear stress on the posterosuperior labral in the late-cocking phase of throwing, which can produce a posterior SLAP lesion. Throwers may feel sharp pain in the extreme abduction/ER position followed by "dead arm" sensation and loss of throwing velocity. • History of falls directly on shoulder, downward force on outstretched arm, or sudden eccentric force on a contracting biceps.

15. Differential Diagnosis • Rotator Cuff Tear (RTC) • Anterior-Inferior Glenohumeral Instability • Athletes: instability may occur with repetitive external rotation with the arm in abduction (apprehension position). • ALPSA: • anterior labroligamentous periosteal sleeve avulsion; medialized Bankart with medial displacement of the torn anterior labrum. • Perthes lesion: nondisplaced labral tear • GLAD lesion: • glenolabral articular disruption: nondisplaced anterior labral tear associated with articular cartilage injury.

16. Differential Diagnosis • CORRELATION BETWEEN BANKART AND HILL-SACHS LESIONS IN ANTERIOR SHOULDER DISLOCATION • A total of 61 patients had an MRI • The MRI scans were reviewed and subsequently confirmed by a radiologist to show the presence or absence of BankartandHill-Sachs lesions • 73% had a Bankartlesion and 67% had a Hill-Sachs lesion on MRI • 64% of those with a Bankart lesion had Hill-Sachs lesions • 70% of those with Hill-Sachs lesions had a Bankartlesion • The correlation between Bankart lesion and Hill-Sachs lesion showed that if one of the lesions was identified, the chance of the other being present was more than two-and-a-half times as likely

17. Diagnosis/Prognosis • Guide to PT Practice- PT Diagnosis • 4I- Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated with Bony or Soft Tissue Surgery • Prognosis • Following physician/PT directions both open and arthroscopic repairs have a good prognosis • Recurrance: • Marquardt, et al: 5.6% failure rate (arthroscopic) • Gartsman et al: 7.5% failure rate (arthroscopic) • Freedman et al: 12.6% arthroscopic vs 3.4% open • Failure to identify bony lesions through arthroscopy (4% failure rate when bony lesions excluded)

18. Problem list/Goals • Problem list • Pain • Decreased ROM • Decreased Strength • Swelling • Goals • Goals will be related to function and will address problems from problem list. • Will address different parts of problem list based on phase of recovery.

19. Sample Goals • Phase one (weeks 0-6): • Following PT intervention, pt will report decrease in pain to 2/10 at rest, in order to sleep through the night, within 2 weeks. • Phase two (weeks 6-12): • Following PT intervention, pt will achieve full shoulder AROM within 10 weeks in order to be independent in ADL’s. • Phase three (weeks 12+) • Following Pt intervention, pt will achieve equal strength, all motions bilateral shoulders, within 16 weeks in order to return to full work responsibilities as a mechanic.

20. Timeline • Stages of Tissue Healing! • Who knows them?

21. Timeline • Stages of tissue healing • Inflammatory stage (0-2 weeks) • Proliferation/Repair stage (days-6 weeks) • Maturation/Remodeling (up to 2 years!) • General Timeline • Return to strenuous work duties • Physician dependent • Generally around 4 months

22. Inpatient care • Today this is an outpatient surgery

23. Outpatient care Comparison of 4 different Bankart Repair protocols Consensus among protocols • Modalities as needed for pain/swelling • Sling until week 6 typically • ROM • Begin pain-Free PROM around week 2 • Brigham and Women’s Hospital: No shoulder movements of any kind until week 4. • Very slow progression of passive ER in scapular plane or at 90 degrees abduction. ER last to regain full motion • Joint Mobilizations • Avoid anterior glides to protect surgical repair • No AROM until around week 6 • Full AROM around week 10

24. Outpatient Care • Strengthening • Pain-free RTC isometrics around week 2 • Begin isotonic shoulder strengthening around week 6 • Slow progression of strengthening exercises • Avoid aggressive strengthening exercises that place stress on anterior capsule (i.e. bench press, push-ups • Equal strength bilaterally around week 14-20 • Return to sport/strenuous work duties • Physician dependent • Pain Free shoulder Function without signs of instability • Full AROM • Equal Strength Bilaterally

25. Outpatient care • Take Home Message • Slow and conservative rehabilitation • Number one priority • Protection of healing tissues!

26. Home Program • Post-op • Ice as needed for pain/swelling • Pendulums • Emphasis on correct form to ensure passive movements • AAROM elbow, wrist, hand • Wound care • Active Motion phase • HEP of specific strengthening/stretching activities • Progression of strengthening exercises as tissue healing occurs

27. Patient Education • Avoid active motion during first 6 weeks • Warn pt of over-compliance • Mechanism of injury • Re-emphasize mechanism as same mechanism is what will cause surgical repair to fail • I.E. forced external rotation and extension • POC • Including problem list, goals, timeline, prognosis • HEP and progression of HEP

28. Decision Tree

29. References • Dumont GD, Russell RD, Robertson WJ. Anterior shoulder instability: a review of pathoanatomy, diagnosis and treatment. Curr Rev Musculoskelet Med. 2011;4(4):200-7. • Freedman KB, Smith AP, Romeo AA, Cole BJ, Bach BR. Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for Recurrent Anterior instability of the shoulder: a meta-analysis. Am J Sports Med. 2004;32(6):1520-7. • Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up. J Bone Joint Surg Am. 2000;82-A(7):991-1003. • Hayes, K., Walton, J. R., Szomor, Z. L., & Murrell, G. A. (2001). Reliability of five methods for assessing shoulder range of motion. Australian Journal of Physiotherapy, 47(4), 289-296. • Kirkley A, Werstine R, Ratjek A, Griffin S. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: long-term evaluation. Arthroscopy. 2005;21(1):55-63. • Lecture by Sue Jeno, PT, PhD. University of North Dakota School of Physical Therapy • Marquardt B, Witt KA, Götze C, Liem D, Steinbeck J, Pötzl W. Long-term results of arthroscopic Bankart repair with a bioabsorbable tack. Am J Sports Med. 2006;34(12):1906-10.

30. References • Rehabilitation Protocol for Arthroscopic Anterior Bankart Repair. Gillette Physical Therapy. Gillette, WY. • Rehabilitation Protocol for Arthroscopic Anterior Bankart Repair and Anterior Stabilization Procedures. Alex Petruska, DPT. Massachusetts General Hospital Sports Medicine. Boston, MA. • Rehabilitation Protocol for Arthroscopic Anterior Stabilization (With or Without Bankart Repair). Brigham and Women’s Hospital. Boston, MA. • Rehabilitation Protocol for Bankart Repair. Sanford Outpatient Physical Therapy. Bismarck, ND. • Roller, A. S., Mounts, R. A., DeLong, J. M., & Hanypsiak, B. T. (2013). Outcome Instruments for the Shoulder. Arthroscopy: The Journal of Arthroscopic & Related Surgery. • Wang RY, Arciero RA, Mazzocca AD. The recognition and treatment of first-time shoulder dislocation in active individuals. J Orthop Sports Phys Ther. 2009;39(2):118-23. • Widjaja AB, Tran A, Bailey M, Proper S. Correlation between Bankart and Hill-Sachs lesions in anterior shoulder dislocation. ANZ J Surg. 2006;76(6):436-8.