Arthroscopic Bankart RepairThe anterior labral complex is composed of the inferior gleno-humeral ligament and anterior la-brum.. It is well appreciated and recognized that an-terior disl
Trang 1Arthroscopic Bankart Repair
The anterior labral complex is composed of the inferior gleno-humeral ligament and anterior la-brum The complex stabilizes the glenohumeral joint by doubling the depth of the glenoid fossa.1Turkel et
al2showed that this soft-tissue com-plex functions to resist anterior dis-location when the shoulder is posi-tioned at 90° of abduction It is well appreciated and recognized that an-terior dislocation is commonly asso-ciated with a Bankart lesion, defined
as a separation of the anterior
inferi-or labral complex from the glenoid rim.3Rowe et al4reported that 85%
of patients with traumatic anterior dislocation had an associated Ban-kart lesion It is well accepted that open repair of the Bankart lesion re-stores anterior stability to the shoul-der joint and is associated with good functional outcomes However, in
1987, Morgan and Bodenstab5
report-ed on the results of arthroscopic re-pair of Bankart lesions in 25 pa-tients; the authors used transglenoid suture fixation with the goal of achieving clinical results similar to those of open repairs while avoiding the surgical dissection associated with open repair All results were rated excellent, and all patients achieved full, painless range of mo-tion
Subsequent studies of
arthroscop-ic Bankart repair showed that the use of osseous anchors leads to
low-er rates of recurrent instability com-pared with transglenoid fixation.6,7 Prospective studies with follow-up
>2 years that compared open versus arthroscopic repair of Bankart le-sions using suture anchors demon-strate no differences in recurrent dis-location rates or clinical outcome scores.8,9 On the contrary, Fabbri-ciani et al9found that arthroscopic repair can lead to greater range of motion compared with open repair
Kim et al10 recently reported the long-term outcome (mean, 44 months) of arthroscopic Bankart re-pair using suture anchors in 167 pa-tients with traumatic recurrent an-terior instability; they found that arthroscopic repair led to
satisfacto-ry outcome in terms of recurrence rate, activity, and range of motion
Indications
The technical demands of advanced arthroscopic shoulder procedures make indications for arthroscopic Bankart repair surgeon-specific First, the surgeon must evaluate his
or her comfort with arthroscopic in-strumentation and techniques Ini-tially, the ideal patient for arthro-scopic repair is one who has had traumatic recurrent anterior insta-bility and failed to respond to phys-ical therapy However, with im-proved understanding of pathology and anatomy, improved instrumen-tation, and improved surgical tech-nique, the indications have
expand-ed to include patients with first-time dislocations, recurrent bidirectional instability, atraumatic instability, and even revision following failed previous repair attempts.11 Arthro-scopic repair in such patients in-volved in high-level contact sports remains controversial, but Pagnani and Dome12reported a 90% success rate after open repair in professional football players
Contraindications
Contraindications to arthroscopic repair include significant osseous de-fects on either the humeral head (large engaging Hill-Sachs lesions) or the glenoid (inverted pear glenoid), and humeral avulsion of the gleno-humeral ligaments (HAGL) lesion Although arthroscopic repair of
vol-Brian Su, MD, and
William N Levine, MD
Dr Su is Postdoctoral Residency Fellow,
Center for Shoulder, Elbow and Sports
Medicine, New York Orthopaedic
Hospital, Columbia University Medical
Center, New York, NY Dr Levine is
Director of Sports Medicine and
Associate Director, Center for Shoulder,
Elbow and Sports Medicine, New York
Orthopaedic Hospital, Columbia
University Medical Center.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr Su and Dr Levine.
Reprint requests: Dr Levine, 622 W
168th Street, PH-1117, New York, NY
10032.
J Am Acad Orthop Surg
2005;13:487-490
Copyright 2005 by the American
Academy of Orthopaedic Surgeons.
The video that accompanies this article is
“Arthroscopic Bankart Repair,” available
on the Orthopaedic Knowledge Online
website, at http://www5.aaos.org/oko/
jaaos/surgical.cfm
Surgical Techniques
Trang 2untary dislocators is
contraindicat-ed, patients who have recurrent
dislocations or capsulolabral
redun-dancy, including multidirectional
instability, are becoming
increasing-ly suitable candidates for
arthroscop-ic repair Finally, patients with
bra-chial plexus or scapulothoracic
dysfunction are not candidates for
arthroscopic repair
Surgical Technique
Our preoperative evaluation
in-cludes a thorough history of the
traumatic event, including arm
posi-tion, energy level, and treatment
compliance The physical
examina-tion focuses on confirming the
diag-nosis with provocative tests such as
apprehension, relocation, anterior
release, anterior and posterior load
and shift, sulcus sign, the
active-compression test, and determination
of ligamentous laxity It is critical to
differentiate anterior instability
sec-ondary to a Bankart lesion from
mul-tidirectional instability, isolated
su-perior labrum anterior posterior
(SLAP) lesions, and generalized
liga-mentous laxity
Examination under anesthesia
provides additional information
re-garding the primary direction of in-stability and should correlate with the preoperative findings Imaging includes a standard shoulder radio-graph series (true anteroposterior [AP], AP in internal rotation, AP in external rotation, axillary, and
later-al scapular Y) that will demonstrate Hill-Sachs lesions and glenoid defi-ciency In some cases, to better char-acterize the labral lesion, a
magnet-ic resonance arthrogram is obtained when the history and physical exam-ination are suggestive of a SLAP le-sion or when magnetic resonance imaging is equivocal
For all arthroscopic procedures, anesthesia is provided by an inter-scalene block In most cases of rou-tine anterior instability, the patient
is placed in the beach chair position, with use of a pneumatic arm holder
The surgeon may use the lateral de-cubitus position, which offers the advantage of joint distraction; how-ever, caution should be exercised be-cause traction injuries to the arm are
a known complication If the lateral decubitus position is used, a com-mercially available arm positioner also is used, and 10 lb of traction is applied to the affected extremity We typically use the lateral decubitus
position in cases of concurrent SLAP tears or posterior labral tears, or in patients with multidirectional insta-bility
Diagnostic arthroscopy begins with a posterior portal 2 cm inferior and 1 cm medial to the
posterolater-al acromion An anterosuperior por-tal is then created under
arthroscop-ic guidance just lateral and superior
to the coracoid so that it pierces the rotator interval and enters the joint level at the insertion of the biceps tendon onto the superior labrum The cannula should be able to be manipulated above and below the bi-ceps tendon ( video steps 1-3) A
second anterior portal at the
superi-or aspect of the subscapularis is then created (anteroinferior) so that su-ture anchors can be placed in the in-ferior glenoid It is important to leave a 3-cm interval between the two anterior portals to allow for ad-equate working space (Figure 1) Of note, threaded cannulas may be use-ful to prevent backout of the cannu-lae during manipulation and knot ty-ing
Diagnostic arthroscopy is per-formed, including evaluation of the glenohumeral ligaments, biceps ten-don, and suspected labral detach-ment The drive-through sign13 is performed by passing the arthro-scope between the humeral head and glenoid at the level of the anterior band of the inferior glenohumeral ligament
The first critical technical step is
to mobilize the labral-ligamentous complex from the anterior glenoid neck with a rasp, electric shaver, or elevator Release of the labrum at the inferior aspect of the glenoid at the 6 o’clock position ( video steps 4-6), and in some cases beyond
the 6 o’clock position, is mandatory
to allow for proper retensioning of the labral-ligamentous complex (Fig-ure 2) The glenoid is then prepared
by decortication with a shaver or burr to a bleeding surface This is done without creating a trough to promote healing of the soft tissue to
Figure 1
External view demonstrating position of anterosuperior and anteroinferior cannulae
Arthroscopic Bankart Repair
Trang 3the bone (Figure 3) The number of
suture anchors used varies with the
degree of labral separation; we
typi-cally use three uniformly spaced
an-chors (on a right shoulder at the 3
o’clock, 4 o’clock, and 5:30
posi-tions) to repair most lesions
The first anchor, located at the
5:30 position, is placed as low as
pos-sible by using the anteroinferior
por-tal ( video step 7) The anchor
must be placed directly on the edge
of the articular surface14(Figure 4)
When a nondisposable single-step
device is used (ie, BirdBeak; Arthrex,
Naples, FL), then both suture limbs
are retrieved through the
anterosu-perior cannula Conversely, when a
shuttle-type device is preferred (ie,
Suture Lasso; Arthrex), then one
su-ture limb is left in the
anteroinferi-or cannula and one is taken out via
the anterosuperior cannula to avoid
suture entanglement ( video step
8).
The capsulolabral tissue is then
captured with the suture-passing
in-strument through the anteroinferior
cannula; our preferred technique uses
a preloaded suture lasso One suture
limb is then secured; using the
niti-nol loop as a lasso, the other limb is
delivered out of the anteroinferior
cannula ( video step 9) The
su-ture tying is done through the
antero-inferior portal The suture anchor must be visible at all times when withdrawing the suture limb from the anterosuperior to the anteroinfe-rior portal to ensure that the suture does not unload from the anchor
This suture, which is the limb that passes through the tissue, acts as the post when the final knot is tied through the anteroinferior cannula
This places the arthroscopic knot fur-ther on the tissue side, creating an anterior buttress, rather than inter-posing the knot between the anchor and soft tissue14(Figure 5)
Any one of many sliding arthro-scopic knots is then placed; our pre-ferred configuration is the Tennessee slider One of the most important
as-pects of using any sliding knot is maintaining loop security before placing any half-hitches If there is any slack in the loop, the knot will tighten around itself rather than around the loop of suture around the soft tissue Three alternating half-hitches are then placed, and the final half hitch is “flipped” to prevent the knot from slipping (knot security) Following placement of the first anchor, the 4 o’clock and 3 o’clock anchors are placed After adequate repair of the labrum, the drive-through sign should no longer be present (Figure 6) Capsular laxity is then assessed through the posterior portal and the anterosuperior portals
to determine the need for an
antero-Figure 3
Anterior viewing portal demonstrating glenoid preparation with a burr to optimize labral-ligamentous healing
The arrow indicates the glenoid/
scapula bone preparation
Figure 4
Posterior viewing portal demonstrating suture anchor placement with sutures directly in the articular cartilage margin
Figure 5
Posterior viewing portal demonstrating the post limb (arrows) through the labral-ligamentous complex
Figure 6
Final posterior view of arthroscopic Bankart repair
Figure 2
Arthroscopic view demonstrating
labral-ligamentous preparation for
arthroscopic repair The large arrows
indicate the labral-ligamentous
complex; the small arrows indicate the
glenoid rim
Brian Su, MD, and William N Levine, MD
Trang 4inferior capsular plication procedure.
Our preferred technique for plication
uses multiple nonabsorbable
su-tures
Pearls
• The anteroinferior and
antero-superior cannulae need to be
placed far apart at the skin
lev-el (at least 3 cm) for ease of
soft-tissue manipulation and suture
management
• The labrum must be mobilized
to the level of the inferior
gle-noid to exclude the possibility
of an anterior labral-periosteal
sleeve avulsion (ALPSA)
le-sion
Pitfalls
• When retrieving any suture for
use in arthroscopic procedures,
always keep the anchor in view
to avoid “unloading” the suture
from the anchor
• Practice these techniques in a
laboratory—the Orthopaedic
Learning Center (OLC), local
laboratory, or industry
labora-tory—to avoid potential
intra-operative complications
Summary and
Conclusions
Arthroscopic Bankart repair has
evolved over the past few decades
from a procedure fraught with
com-plications to one with decreased
pain and improved functional
out-come, with little recurrence of
insta-bility With appropriate patient
se-lection and knowledge of technical
considerations, such as anchor
placement and suture management, the results of arthroscopic Bankart repair are approaching those of the traditional gold standard, open re-pair In addition, cost analysis of ar-throscopic versus open Bankart re-pair shows that the arthroscopic repair is a more time-efficient oper-ation and results in lower overall to-tal costs.15
Our preferred technique for Ban-kart repair includes using two work-ing anterior portals separated by at least 3 cm for ease of suture manage-ment Our technique also includes the use of suture anchors because they have shown superior clinical re-sults compared with transglenoid or tack repairs Although the use of any one of many multiple suture-passing devices and sliding knot configura-tions is acceptable, it is important to adhere to principles such as ade-quate mobilization of the labrum, glenoid preparation, and appropriate loop security before locking the knot Finally, arthroscopic labral re-pair has the distinct advantage of ad-dressing concomitant lesions identi-fied at the time of surgery, such as SLAP tears, posterior labral tears, ro-tator cuff tears, roro-tator interval tears, and capsular laxity
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Arthroscopic Bankart Repair