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

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 5 th 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 Stability50 pts Motion20 pts Function30 pts Excellent 90 to 100 Good75 to 89 Fair51 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) 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 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 ArthrOpen No. Pt’s3722 Age2827 F/U yrs4.44.5

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 ArthrOpen Recurrence16%9% Mean Rowe8382 G/E Rowe76%77% 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 ArthrOpen No. Pt’s6048 Age2627 F/U yrs2.43

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 ArthrOpen Recur. Inst.15%10% Mean Rowe* *90 deg80 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 ArthrOpen No. Pt’s3026 Age F/U yrs22

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 ArthrOpen Recur. Inst.23%12% Rowe – stable sh’s10095 Loss of ER9 deg10 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 ArthrOpen No. Pt’s5930 Age F/U yrs

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 ArthrOpen Recur. Inst.3.4%6.7% Rowe * Avg Loss of ER4 deg6 deg >10 deg loss ER7%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 ArthrCons No. Pt’s912 Age22 (19-26)23(19-26) F/U yrs

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 ArthrCons Recur. Inst.11%75% SANE Score8857* L’Insalata Score9473* Loss of ER4 deg3 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 Assessment15 pts Pain40 pts Daily Activities20 pts Recreation/Athletic Activities15 pts Work10 pts

First Time Dislocators Bottoni AJSM 2002 –1 failure of arthroscopic tx underwent open repair –6 failures of the closed tx underwent open repair