arthroscopic vs. open bankart repair where are we today? bill wiley orv october 24, 2002
TRANSCRIPT
Arthroscopic vs. Open Bankart Repair
Where are we Today?Bill Wiley ORV October 24, 2002
History
• Traumatic
• Documented direction
• Position of Arm at time of dislocation– Abduction and External Rotation
• Young male
• First time vs. Recurrent
• Voluntary
Physical Exam
Physical Exam• Neurologic Status of Axillary Nerve
– Sensation– Motor
• ROM– Dominant Side has Increased ER– Pitchers have Increased ER
• Status of Rotator Cuff• Apprehension Sign• Relocation Test• Sulcus Sign > 2 cm
Physical Exam
• Load and Shift Test (Silliman & Hawkins)– Grade I – humeral rides up to edge of glenoid– Grade II – humeral head goes over glenoid but
reduces spontaneously– Grade III – humeral head stays dislocated
• Good to do in EUA on both shoulders
Physical Exam
• Beighton Hypermobility Score (9 possible)– DF 5th MCP >90 (each side 1)– Thumb to Volar Wrist (each side 1) – Hyperextend Elbow >10 (each side 1)– Hyperextend Knee >10 (each side 1)– Hands flat on Floor
Physical Exam
• Other Hypermobility Signs and Tests– Other Shoulder ER at 90 ABD >90– Finger DIP DF >60– Thumb MP Hyperext >90– Widened Scars– Marfanoid Habitus
Imaging Studies
• AP in scapular plane• Lateral (Axillary/Scapular Y)• Other Views:
– Stryker Notch– Hill Sachs View– West Point Axillary– Velpeau Axillary
Stryker Notch
Apical Oblique/Garth View
Imaging Studies
• CT Scan– Glenoid Deficiency– Humeral Head Deficiency
• MRI– With or W/O Gadolinium– Adducted and Abduction/Ext Rot.
History of Bankart Lesion
• Described by Perthes in 1906
• Bankart reported on 27 cases in 1923
Rowe Outcome Measure
• Stability 50 pts• Motion 20 pts• Function 30 pts
• Excellent 90 to 100• Good 75 to 89• Fair 51 to 74• Poor <50
Results of Open Bankart
• Rowe JBJS 1978– 145 patients– Avg F/U 6 yrs– 3.5% Recurrence– 69% Full ROM– 97% G/E Rowe Score
Results of Open Bankart
• Thomas, Matsen JBJS 1989– 39 shoulders– Avg F/U 5.5 yrs– 2.5% Recurrence (however 5% had symptoms)– ER @ 90 Deg 84 (range 43 to 108)– 97% G/E Rowe Score
Results of Open Bankart
• Thomas, Matsen JBJS 1989– Classic Article where described
• TUBS (Traumatic, Unidirectional, Bankart, Surgery)
• AMBRI (Atraumatic, multidirectional, bilateral, rehabilitation, inferior shift)
Results of Open Bankart
• Jobe AJSM 1991– 25 skilled athletes– Avg F/U 3.3 yrs– No Recurrence– 18/25 returned to competitive level– 8 pt’s had loss of ER (avg 12 deg)– 92% G/E Mod Rowe Score
Arthroscopic Grading
• Baker AJSM 1990 – 45 first time dislocations, Avg 21yoa – Group I (13%) – no labral lesion, capsular tear– Group II (24%) – partial labral detachment
w/capsular tear– Group III (62%) – complete labral detachment
w/capsular tear
Other Arthroscopic Findings
• Wolf Arthroscopy 1995 – 9.3% HAGL
Other Arthroscopic Findings
• Neviaser 1993 – ALPSA (Anterior Labroligamentous Periosteal Sleeve Avulsion)
Other Arthroscopic Findings
• GARD Lesion – Glenoid Articular Rim Disruption. Posterior labral tear in association w/osseous defect of posterior glenoid (Chan 1998)
Other Arthroscopic Findings
• GLAD Lesion – Glenolabral Articular Disruption. Tear of anteroinferior labrum w/glenoid articular cartilage injury. No instability on exam, MoI – forced ADD from ABD/ER (Neviaser 1993)
• Bennett Lesion – Posteroinferior ossification/calcification associated with Posterior labral tear (1941)
Other Arthroscopic Findings
• SLAC Lesion – Superior Labrum Anterior Cuff lesion (Savoie OCNA 2001)– Injury to the Superior Anterior glenoid labrum
that involves the insertion of the SGHL and the anterior portion of the biceps tendon
– Allows the undersurface of the supraspinatus tendon to contact the AS glenoid and cause a tear
Considerations
• Drive Through Sign (92% Sens, 38% Spec, McFarland 2001)
• Size of Hill-Sachs Lesion• Associated Rotator Cuff
Tear• Capsular Redundancy• Other Fractures
Arthroscopic Bankart
• Gartsman JBJS 2000– Prospective Outcome study– 60 patients– 53 pt’s (88%) Follow-up– Avg Age 32 yrs– Avg F/U 33 months– Single Surgeon
Arthroscopic Bankart
• Gartsman JBJS 2000– Stepwise Technique:
• Repair Labral tears (48)
• Capsular Tensioning – to prevent translation over 25% of glenoid:
– Adv Capsule to labrum/glenoid (46)
• Rotator Interval Closure (14)
• Thermal Capsulorrhaphy - Laser (48)
Arthroscopic Bankart
• Gartsman JBJS 2000– Suture anchors used in 52 patients (1 to 5)– Wide range of suture anchor types– Currently using metallic screw in anchor
Arthroscopic Bankart
• Gartsman JBJS 2000– Results
• Rowe Score improved from 11 to 92• 92% G/E Rowe Score• 9% w/>5 degree loss of ER• 8% Recurrent Instability
Arthroscopic Bankart
• Noojin, Savoie Orthop Today 2000– Prospective Consecutive Series– 35 patients– 2 Surgeons– Mean Age of 27– Minimum 2 yr F/U (24-36 mo.)
Arthroscopic Bankart
• Noojin, Savoie Orthop Today 2000– Technique:
• Used a minimum of 3 Panalok Anchors with single loaded Panacryl Suture
• Also Closes the Rotator Interval
Arthroscopic Bankart
• Noojin, Savoie Orthop Today 2000– Results
• 170 Degrees FE• ER @ 90 avg 110 Degrees• Avg Rowe Score of 93• 1 (3%) Redislocation
Arthroscopic Bankart
• Thal CORR 2001– Prospective Outcome Evaluation– Using the Knotless metallic GII-like suture
anchor (now Mitek has bioabsorbable)– 27 patients– Avg Age 28 yrs– Avg F/U 29 mo– Single Surgeon
Arthroscopic Bankart
• Thal CORR 2001
Arthroscopic Bankart
• Thal CORR 2001
Arthroscopic Bankart
• Thal CORR 2001– Results
• 5 patients had SLAP repair• All satisfied• 1 (4%) pt traumatic recurrent dislocation• 2 (7%) pts 10 deg loss of ER at 90 deg
Comparison Studies
• Cole, Warner JBJS 2000– Prospective Nonrandomized evaluation of their
selection criteria– 59 patients– 94% Followup– Selection Criteria to go Open Shift:
• EUA: 2+ or greater ant & inf translation• Arthroscopic Exam: capsular rupture or thinning,
combined capsular laxity w/Bankart lesion
Comparison Studies
• Cole, Warner JBJS 2000
Arthr Open
No. Pt’s 37 22
Age 28 27
F/U yrs 4.4 4.5
Comparison Studies
• Cole, Warner JBJS 2000– Arthroscopic Technique: 2 or 3 suretac– Open Technique: bankarts repaired and then
anteroinferior humeral capsular shift (do not mention how bankarts were repaired)
Comparison Studies
• Cole, Warner JBJS 2000
Arthr Open
Recurrence 16% 9%
Mean Rowe 83 82
G/E Rowe 76% 77%
ER @ 90 -6 deg -8 deg
None of these were statistically different
Comparison Studies
• Karlsson AJSM 2001– Prospective, Nonrandomized based on patient
choice– 3 Surgeons– 119 Shoulders– 91% Followup– Excluded if no bankart lesion and converted to
open capsular shift
Comparison Studies
• Karlsson AJSM 2001
Arthr Open
No. Pt’s 60 48
Age 26 27
F/U yrs 2.4 3
Comparison Studies
• Karlsson AJSM 2001– Arthroscopic Technique: 2 or 3 Suretac– Open Technique: 2-4 TAG (Acufex – 24 pt’s)
or Mitek (29 pt’s) suture anchors, using modified Rowe Technique
Comparison Studies
• Karlsson AJSM 2001
Arthr Open
Recur. Inst. 15% 10%
Mean Rowe* 93 89
ER @ 90* 90 deg 80 deg
*Statistically Different
Comparison Studies• Sperber, Karlsson JSES 2001
– Prospective, Randomized Multicenter Study
– 7 Surgeons
– 56 patients
– Inclusion: >17 yoa, unilateral, recurrent anterior instability w/arthroscopically verified bankart lesion
– Exclusion: primary dislocation < 3 mo, bilateral instability, MDI, additional soft-tissue injuries
Comparison Studies
• Sperber, Karlsson JSES 2001
Arthr Open
No. Pt’s 30 26
Age 25 27.5
F/U yrs 2 2
Comparison Studies
• Sperber, Karlsson JSES 2001– Arthroscopic Technique: 1-3 Suretac
– Open Technique: 1-4 anchors by choice of the surgeon w/capsular shift as needed
Comparison Studies
• Sperber, Karlsson JSES 2001
Arthr Open
Recur. Inst. 23% 12%
Rowe – stable sh’s 100 95
Loss of ER 9 deg 10 deg
None of these were statistically different
Comparison Studies
• Kim Arthroscopy 2002– Retrospective Case Control Study– Early part did open, Later arthroscopic– 93 Shoulders– 96% available for F/U– 1 Surgeon– Only Study to compare arthroscopic and open
bankart repair using suture anchors in both
Comparison Studies
• Kim Arthroscopy 2002
Arthr Open
No. Pt’s 59 30
Age 25.3 25.2
F/U yrs 2.8 4.1
Comparison Studies
• Kim Arthroscopy 2002– Arthroscopic Technique: 3-6 mini-Revo screw
suture anchors, No. 2 ethibond– Open Technique: 2-3 Mitek suture anchors,
No. 2 ethibond
Comparison Studies
• Kim Arthroscopy 2002
Arthr Open
Recur. Inst. 3.4% 6.7%
Rowe 92.7 90.4*
Avg Loss of ER 4 deg 6 deg
>10 deg loss ER 7% 23%*
*p<0.05
First Time Dislocators
• Reasons for Arthroscopic Tx– Up to 90% Recurrence in those under 21– Address associated pathology– Repair Tissue while still in good condition
First Time Dislocators
• Bottoni AJSM 2002– Prospective Randomized Trial– Army Population– 24 patients– 88% F/U– Min F/U 16 months
First Time Dislocators
• Bottoni AJSM 2002
Arthr Cons
No. Pt’s 9 12
Age 22 (19-26) 23(19-26)
F/U yrs 2.9 3.1
First Time Dislocators
• Bottoni AJSM 2002– Used suretacs– 2 tacks in 9, 3 in 1 patient– Return to Full Active duty by 4 months– Rehab same for both groups
First Time Dislocators
• Bottoni AJSM 2002
Arthr Cons
Recur. Inst. 11% 75%
SANE Score 88 57*
L’Insalata Score 94 73*
Loss of ER 4 deg 3 deg
*p<0.002
SANE Score (AJSM 1999)
• Single Assessment Numeric Evaluation– How would you rate your shoulder today as a
percentage of normal? (0 to 100% w/100% being normal)
– Correlated well w/Rowe and ASES shoulder scores
L’Insalata Score JBJS 1997
• Global Assessment 15 pts
• Pain 40 pts
• Daily Activities 20 pts
• Recreation/Athletic Activities 15 pts
• Work 10 pts
First Time Dislocators
• Bottoni AJSM 2002– 1 failure of arthroscopic tx underwent open
repair– 6 failures of the closed tx underwent open
repair