1. ARTHROSCOPIC BANKART REPAIR T. Andrew Israel, MD Luther Midelfort Orthopaedic & Sports Medicine Center

2. ARTHROSCOPIC BANKART REPAIR Historical Considerations Current Understandings Surgical Goals Advantages of Arthroscopic vs Open Selection Criteria- preop & intraop Surgical Technique Results

3. 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

4. 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

5. SURGICAL GOALS Anatomic reconstruction Reconstruction which approximates an open repair Ability to manage Bankart lesion and capsular laxity Immediate strength of repair

6. 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

7. PREOPERATIVE SELECTION CRITERIA Traumatic instability( subluxation or dislocation ) Minimal bony lesion(s) Discrete Bankart lesion No generalized ligamentous laxity

8. INTRAOPERATIVE SELECTION CRITERIA OPTIMAL FACTORS Discrete Bankart lesion Robustcapsuloligamentous tissue No Bony Bankart lesion No significant loss of articular surface( glenoid or humeral head )

9. INTRAOPERATIVE SELECTION CRITERTA MITIGATING FACTORS Capsular laxity ALPSA( Anterior Labral Periosteal Sleeve Avulsion Injury ) Bony Bankart lesion

10. SURGICAL TECHNIQUE Position Portal placement Identify pathology Mobilize capsulolabral tissue Glenoid preparation Anchor placement Suture retrieval Knot tying

11. POSITION Lateral decubitus Allows for traction Improved exposure to glenohumeral joint

12. 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

13. IDENTIFY PATHOLOGY Bankart lesion Quality of capsulolabral tissue Concomitant SLAP lesion Rotator cuff injuries Injury to articular surfaces

14. MOBILIZE CAPSULOLABRAL TISSUE Arthroscopic elevators Mitek VAPR Strip off capsulolabral sleeve to muscle of subscapularis

15. GLENOID PREPARATION Decorticate juxta-articular scapular neck Curette Rasp Shaver

16. 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

17. 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

18. KNOT TYING Perfect knots Flawlessly perfect knots

19. 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%)

20. CASE PRESENTATION

21. 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

22. PHYSICAL EXAM AROM 175/175, 65/75, T12/T10 5/5 power abduction & external rotation 2+ anterior/inferior laxity with endpoint Positive Jobes anterior apprehension/relocation test Negative sulcus sign

30. SHOULDER ANATOMY

31. SURGERY

32. 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