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ARTHROSCOPIC BANKART REPAIR. T. Andrew Israel, MD Luther 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

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Arthroscopic bankart repair

ARTHROSCOPIC BANKART REPAIR

T. Andrew Israel, MD

Luther Midelfort Orthopaedic & Sports Medicine Center


Arthroscopic bankart repair1
ARTHROSCOPIC BANKART REPAIR

  • Historical Considerations

  • Current Understandings

  • Surgical Goals

  • Advantages of Arthroscopic vs Open

  • Selection Criteria-preop & intraop

  • Surgical Technique

  • Results


Historical considerations
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
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
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
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
PREOPERATIVE SELECTION CRITERIA

  • Traumatic instability(subluxation or dislocation)

  • Minimal bony lesion(s)

  • Discrete Bankart lesion

  • No generalized ligamentous laxity


Intraoperative selection criteria optimal factors
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
INTRAOPERATIVE SELECTION CRITERTA MITIGATING FACTORS

  • Capsular laxity

  • ALPSA(Anterior Labral Periosteal Sleeve Avulsion Injury)

  • Bony Bankart lesion


Surgical technique
SURGICAL TECHNIQUE

  • Position

  • Portal placement

  • Identify pathology

  • Mobilize capsulolabral tissue

  • Glenoid preparation

  • Anchor placement

  • Suture retrieval

  • Knot tying


Position
POSITION

  • Lateral decubitus

  • Allows for traction

  • Improved exposure to glenohumeral joint


Portal placement
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
IDENTIFY PATHOLOGY

  • Bankart lesion

  • Quality of capsulolabral tissue

  • Concomitant SLAP lesion

  • Rotator cuff injuries

  • Injury to articular surfaces


Mobilize capsulolabral tissue
MOBILIZE CAPSULOLABRAL TISSUE

  • Arthroscopic elevators

  • Mitek VAPR

  • Strip off capsulolabral sleeve to muscle of subscapularis


Glenoid preparation
GLENOID PREPARATION

  • Decorticate juxta-articular scapular neck

  • Curette

  • Rasp

  • Shaver


Anchor placement
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
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
KNOT TYING

  • Perfect knots

  • Perfect knots

  • Flawlessly perfect knots


Results gartsman jbjs 2000
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 j h
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
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




Summary
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