Shoulder Arthroscopic Bankart Repair

Figure 18-1 A, Anteroposterior radiograph of an anterior glenohumeral dislocation. B, Normal (reduced) anteroposterior radiograph of the glenohumeral joint. C, Scapular lateral radiograph of an anterior glenohumeral dislocation. D, Normal axillary lateral radiograph. E, West Point axillary lateral with irregularity at the anteroinferior edge (arrow) consistent with a bony Bankart.

Periscapular
Figure 18-2 A magnetic resonance arthrogram with the shoulder in an abducted and externally rotated position demonstrating a Bankart lesion (arrow).

Anterior Instability

Rehabilitation with an emphasis on periscapular muscle strengthening is typically the first course of treatment prescribed for patients with anterior shoulder instability. The improvement in periscapular muscles and proprioception can allow a patient to function with the instability. With an increased awareness of the provocative position of humeral abduction and external rota-

Figure 18-3 Arthroscopic image of a Hill-Sachs lesion following a traumatic dislocation. Note cartilage on both sides of the osteochondral injury.

tion, patients can, at times, return to sports. Orthotics that limit humeral abduction and/or external rotation can be used to allow an athlete to complete a season. However, many athletes have persistent symptoms that preclude return to their prior sports or activities despite a course of physical therapy. In these cases, a surgical repair is recommended. Indications for surgical stabilization include shoulder instability that has failed nonoperative treatment and precludes return to preinjury activities.

First-Time Shoulder Dislocations

Controversy exists as to whether athletes should be offered surgical stabilization after a single first-time anterior shoulder dislocation. Nonoperative treatment, which typically entails a brief period of immobilization, followed by a variable duration of rehabilitation, has resulted in recurrent instability rates ranging from 17% to 96% in patients younger than 30 years of age. Because of this high rate of recurrence in young patients, some authors have investigated the role of arthroscopic treatment of shoulders following dislocation. The Bankart lesion has been demonstrated to occur in over 95% of traumatic dislocations. In two prospective, randomized studies of young, first-time dislo-cators, Kirkley et al18 and Bottoni et al19 reported significantly lower recurrence rates following arthroscopic Bankart repair when compared to nonoperative treatment. Additionally patients treated surgically demonstrated a superior outcome compared to the nonoperative group using a quality-of-life assessment.

The decision to surgically stabilize a shoulder that has recently dislocated is made with the expectation that the risks incurred by nonoperative treatment outweigh those incurred by surgery. The major risk of nonoperative treatment is recurrent instability and the additional glenohumeral injury sustained by repeated dislocation episodes. Although the rate of recurrence is high in young athletes, it is not 100%. Therefore, an unknown number of patients will be undertaking surgery unnecessarily, the chief argument for those advocating nonoperative management. However, given the high rate of recurrence and the disability following any subsequent episodes of instability, a patient may conclude that choosing the time of disability, i.e., postoperative rehabilitation, will most likely decrease the risk of subsequent instability episodes significantly. This is the argument presented for operative stabilization. In certain situations, such as the collegiate athlete with a limited number of seasons of competition available, the risk of recurrence in the following season is not acceptable to the athlete and early stabilization is often selected.

Operative Treatment and Preoperative Assessment

Traditionally, open Bankart repair with capsulorrhaphy has been the most reliable technique to restore stability. The goal, whether approached via open or arthroscopic means, is to anatomically repair the avulsion of the anteroinferior capsulo-labral complex and to eliminate capsular redundancy that can contribute to increased anterior humeral translation. All shoulders undergoing stabilization should be examined under anesthesia to assess glenohumeral laxity. This allows an accurate assessment of humeral translation without the effect of muscular contractions in an apprehensive patient. The examination should be compared to the contralateral shoulder (assuming it is normal) to determine asymmetrical increased glenohumeral laxity.

An initial diagnostic glenohumeral arthroscopy should be performed to assess intra-articular pathoanatomy in all patients. This provides several benefits including the opportunity to assess the intra-articular anatomy, confirm the presence of a Bankart lesion, and contrast intraoperative findings with preoperative radiographic studies. Most importantly, the superior labrum is best evaluated and treated arthroscopically. The repair of an unstable SLAP lesion is nearly impossible from an open approach. Additionally, the rest of the intra-articular structures including the posterior labral attachment can be quickly and easily assessed from an initial arthroscopic glenohumeral evaluation.

Operative Techniques Open Anterior Stabilization

The beach chair position for the initial glenohumeral arthroscopy will facilitate positioning for the open procedure. After arthroscopic evaluation and superior labral repair, if indicated, the back of the surgical table is lowered to a recumbent position. The operative extremity can be supported on a padded Mayo stand or a commercially available arm holder. Through a deltopectoral approach, the cephalic vein is identified and retracted laterally. A self-retraining retractor is used to maintain the conjoined tendon medially. The clavipectoral fascia is cleared to allow identification of the anterior humeral circumflex vessels (often referred to as the "three sisters"). These vessels can be safely cauterized without risk to the humeral head. For better exposure inferiorly, the superior portion of the pectoralis tendon as it inserts into the humerus can be incised.

With the arm in adduction and slight external rotation, the subscapularis tendon is tensioned and then longitudinally sectioned approximately 1 cm from its insertion on the lesser tuberosity. Typically, only the superior two thirds of the tendon is transected since the inferior third is mostly muscle. The sub-scapularis is then carefully separated from the underlying capsule. This is more easily performed from inferior to superior. The lateral end of the sectioned subscapularis tendon is secured with three no. 2 nonabsorbable sutures (FiberWire, Arthrex, Inc., Naples, FL). The tendon is retracted medially and secured beneath the self-retaining retractor. Superiorly, between the anterior edge of the supraspinatus and the superior edge of the subscapularis, the rotator interval, a variable area of capsular deficiency often exists. The rotator interval capsular defect, if present, is closed in a side-to-side manner with nonabsorbable sutures. Next, a longitudinal capsulotomy, 5 mm medial to the humeral capsular insertion, is made. Perpendicular to this cap-sulotomy, a horizontal capsular incision is made to the anteroin-ferior glenoid to allow adequate exposure of the Bankart lesion. This horizontal capsulotomy is made at the level of the inferior glenoid to facilitate exposure and repair of the Bankart lesion. A humeral head retractor locked on the posterior glenoid maintains this exposure (Fig. 18-4). Diligent hemostasis is maintained throughout the approach to ensure adequate visualization of the capsulolabral repair.

Anatomic labral repair is next performed using bone tunnels or, more commonly, suture anchors (Fig. 18-5). Typically three anchors are used to repair the Bankart lesion. We prefer bioab-sorbable suture anchors (Bio-FASTak, Arthrex, Inc.) for all labral repairs. The anchors do not obstruct any future radiographic studies and allow strong fixation of soft tissue to bone. Following Bankart repair, a lateral-based capsular shift is used to eliminate redundancy while the humerus is maintained in at least 45 degrees of abduction and 45 degrees of external rotation. The

Superior Humeral Head Retractor
Figure 18-4 The humeral head retractor levers on the anterior edge of the glenoid and retracts the head (arrows) laterally. This maneuver facilitates the Bankart repair to the glenoid (asterisk).

axillary pouch is palpated with one finger while the sutures secured to the lateral edge of the capsule are pulled superiorly. The capsule is sharply released from its humeral insertion, and nonabsorbable sutures are placed along the lateral edge every centimeter. An adequate capsular shift is accomplished when the capsular redundancy is eliminated through superior advancement of the inferior capsular leaf. While releasing the inferior capsule, the axillary nerve, coursing just distal to the inferior glenoid, is identified and protected. Capsular imbrication is then performed in a "pants over vest" technique by advancing the inferior leaflet superiorly along the lateral capsular margin and then reinforcing the repair with the overlapping superior leaflet. If the lateral edge of the tendon is tenuous, a suture anchor can be inserted into the humerus at the 6 o'clock position. We prefer a double-loaded bioabsorbable anchor (Bio-Corkscrew, Arthrex, Inc.). This provides secure capsular fixation at the lateral capsular margin. Anatomic repair of the subscapularis is performed in an end-to-end fashion with the previously placed sutures.

Arthroscopic Technique

Arthroscopic labral repair can be performed in the beach chair or lateral decubitus position. The beach chair position facilitates conversion, if necessary, to an open procedure more easily. However, the lateral decubitus position with overhead traction allows for greater joint distraction and better visualization. Following an examination under anesthesia in the supine position, the patient is then placed in either the lateral decubitus or upright beach chair position. In the lateral position, the patient's operative extremity is maintained in 40 degrees of abduction and slight forward flexion with an overhead traction crane (Fig. 18-6; 3-Point Shoulder Distraction System, Arthrex, Inc.). A standard posterior arthroscopy portal is established first. Two anterior portals are then established from the outside in after proper localization with an 18-gauge spinal needle. A 6.5-mm clear cannula (Stryker Endoscopy, San Jose, CA) is inserted anterosuperiorly at the level of the long head of the biceps tendon. This is called the anterosuperior portal. An 8.4-mm clear cannula (Linvatec, Largo, FL) is inserted just above the subscapularis tendon (Fig. 18-7). This is called the anteroinferior portal. A systematic glenohumeral examination from both

Linvatec Shoulder Cannula

Figure 18-5 A, Cadaveric right shoulder with a Bankart lesion (arrows). B, An arthroscopic image from the anterosuperior portal of a right shoulder with a Bankart lesion.

Figure 18-5 A, Cadaveric right shoulder with a Bankart lesion (arrows). B, An arthroscopic image from the anterosuperior portal of a right shoulder with a Bankart lesion.

the anterior and posterior portals is conducted. If an unstable superior labral lesion is found, it is repaired prior to the anterior stabilization. The technique for SLAP repairs is well described in Chapter 22.

The anteroinferior labral attachment often heals along the medial face of the glenoid following traumatic disruption from a dislocation. The anterior labral-periosteal sleeve avulsion (ALPSA) lesion needs to be completely released from the underlying glenoid (Fig. 18-8). The anteroinferior labrum is separated completely from the glenoid with an arthroscopic eleva tor (Fig. 18-9). The capsulolabral attachment, once completely free, should easily be brought up onto the glenoid with an arthroscopic grasper inserted through the anterosuperior portal. Following release of the capsular soft tissue, an aggressive shaver or bur is used to decorticate the anterior glenoid and stimulate a bleeding bed to which the capsulolabral tissue will be reattached (Fig. 18-10A). To better visualize the anterior glenoid

Lateral Shoulder Arthroscopy Drape

Figure 18-6 Intraoperative radiograph demonstrating lateral decubitus positioning of patient using the shoulder distraction crane. The bony landmarks have been identified to assist with portal placement. Additionally, the edges of the sterile drape have been sealed with Ioban strips to prevent leakage of arthroscopic fluid onto the patient.

Figure 18-6 Intraoperative radiograph demonstrating lateral decubitus positioning of patient using the shoulder distraction crane. The bony landmarks have been identified to assist with portal placement. Additionally, the edges of the sterile drape have been sealed with Ioban strips to prevent leakage of arthroscopic fluid onto the patient.

Figure 18-7 Arthroscopic image of the two anterior cannulas. The smaller cannula (double arrows), the anterosuperior portal, is positioned superior to the biceps tendon, and the larger of the two (single arrow) is the anteroinferior portal and is used for instrumentation.

Periosteal Sleeve Shoulder
Figure 18-8 Arthroscopic image of a right shoulder from the anterosuperior portal with an anterior labral-periosteal sleeve avulsion (ALPSA) lesion (arrows). The labral attachment was avulsed from the glenoid (asterisk) and subsequently healed in a nonanatomic, medial location.

during preparation, the 30-degree arthroscope can be inserted down the anterosuperior portal (see Fig. 18-10B); alternatively, a 70-degree arthroscope will allow excellent visualization from the posterior portal.

Serving as a temporary shuttle stitch, a no. 1 PDS II (Ethicon, Inc., Somerville, NJ) suture is passed through the capsule and

Liberator Arthroscopic Elevator
Figure 18-9 Arthroscopic image of a right shoulder demonstrating the use of an arthroscopic elevator (Liberator, Linvatec, Largo, FL) to release the labrum from the glenoid in preparation for the repair.

Figure 18-10 A, Arthroscopic image of the glenoid abrasion and release of the labrum viewed from the posterior portal. B, Arthroscopic image of the glenoid abrasion viewed from the anterosuperior portal. The labrum is completely released from the glenoid (asterisk).

Figure 18-10 A, Arthroscopic image of the glenoid abrasion and release of the labrum viewed from the posterior portal. B, Arthroscopic image of the glenoid abrasion viewed from the anterosuperior portal. The labrum is completely released from the glenoid (asterisk).

labrum in separate passes using a 45-degree Spectrum Shuttle (Linvatec, Largo, FL) inserted through the anteroinferior portal (Fig. 18-11). Through the anteroinferior portal, a bioabsorbable suture anchor (Bio-FASTak, Arthrex, Inc.) is then inserted at the articular margin of the glenoid (Fig. 18-12). The inferior limb of the permanent suture from the anchor is then retrieved out the anterosuperior portal with a ring grasper (Fig. 18-13). Outside the cannula, the PDS shuttle suture is tied to the

Bankart Procedure Wiki

Figure 18-13 Through the anterosuperior portal, a ring grasper is used to retrieve one limb of the permanent suture and pull it out the anterosuperior portal. This limb is anterior or the one closer to the capsulolabral complex (arrow).

Figure 18-11 Arthroscopic image of the suture hook inserted through the anteroinferior portal and passed through the capsule. The second passage will be through the labrum. One suture has been already completed.

Figure 18-13 Through the anterosuperior portal, a ring grasper is used to retrieve one limb of the permanent suture and pull it out the anterosuperior portal. This limb is anterior or the one closer to the capsulolabral complex (arrow).

suture limb from the anchor with a leading dilation knot that will facilitate passage of both sutures back through the tissue (Fig. 18-14). The shuttle suture is then pulled back through the anteroinferior portal, thus pulling the permanent anchor suture through the labrum and capsule. From the anteroinferior portal, an arthroscopic sliding knot with alternating half hitches secures the tissue to the bone. This process is repeated to effect a capsular imbrication of the anteroinferior capsule and anatomic Bankart repair (Fig. 18-15).

Postoperative Treatment

Following anterior stabilization with either open or arthroscopic techniques, we immobilize the shoulder in a Cryo/Cuff sling (Aircast, Inc., Summit, NJ). The rehabilitation protocol consists of three stages, each lasting approximately 1 month. The first stage consists of immobilization in a sling where we encour-

Sling Suture Technique

Figure 18-14 The PDS suture (single arrow) is tied to the permanent suture (double arrows) outside of the anterosuperior portal cannula. This allows the PDS II to pull the permanent suture back into the joint and through the capsulolabral tissue.

Figure 18-12 Arthroscopic image of the drill guide and suture anchor drill. Note placement several millimeters onto articular margin. The purple PDS II shuttle suture is passing across the guide into the anterosuperior portal.

Figure 18-14 The PDS suture (single arrow) is tied to the permanent suture (double arrows) outside of the anterosuperior portal cannula. This allows the PDS II to pull the permanent suture back into the joint and through the capsulolabral tissue.

Arhtroscopic Shoulder Plication
Figure 18-15 Arthroscopic image of completed Bankart repair with capsular plication.

age pendulum and elbow exercises. Immediate active motion in the forward plane is allowed, but abduction and external rotation are avoided. The second stage involves restoration of a full active range of motion while protecting the repair from aggressive abduction or external rotation. In the third stage, the focus is on periscapular muscular strengthening. Slight modifications by the therapists are allowed based on each individual's progress. Return to sport activities is permitted at 4 to 6 months depending on return of function and strength.

Revision Stabilization

The approach to revision surgery for recurrent anterior instability should begin with a careful assessment of why the instability recurred and whether another surgical procedure will improve the patient's function. The following questions need to be answered to determine the cause and to plan the treatment of the recurrent instability.

1. Did the patient return to normal function and shoulder stability following the previous surgery?

2. Did a subsequent glenohumeral dislocation or subluxation occur?

3. What is the direction of instability, i.e., anterior, posterior, or inferior?

4. Does the patient have generalized ligamentous laxity or a collagen disorder?

5. Are there any radiographic findings that intimate problems with the previous surgery?

Preoperative Assessment

Revision surgery, whether performed open or arthroscopically, is typically more challenging than primary stabilization. The direction of the instability is an important determination. Missed posterior labral injuries or anterior repairs made too tightly can result in postoperative posterior instability. Specific tests to evaluate for posterior glenohumeral pathology, as described in Chapter 19, are performed. The patient should be queried as to the timing of the recurrent instability. For recurrent anterior instability due to subsequent trauma when normal function and stability were restored after the surgery, a recurrent capsulo-labral injury is a likely cause. For recurrent instability that develops insidiously without a definitive traumatic event, a specific cause for the failed surgery needs to be ascertained. Generalized ligamentous laxity and multidirectional instability can be a difficult problem to tackle. More information and surgical tips to address multidirectional instability and capsular injuries are offered in Chapter 20.

Preoperative evaluation of recurrent anterior instability should follow that prescribed for primary instability. The operative report, if available, should be obtained to ascertain what type of approach and fixation were used in the previous surgery. Plain radiographs should be used to assess bony injuries or glenoid insufficiency as well as retained hardware. Placement of suture anchors can provide clues for failure of the previous surgery. Suture anchors placed too far medially (Fig. 18-16) instead of up on the articular margin or placed too superiorly to adequately address the anteroinferior capsulolabral laxity may contribute to recurrent instability. If metallic suture anchors are in the correct position, they may preclude placement of new suture anchors or necessitate alternative methods of fixation in the revision surgery. Although postoperative changes may make the interpretation more difficult, magnetic resonance imaging or preferably magnetic resonance arthrography should be obtained to assess for capsulolabral reinjury. Superior labral injuries, if not addressed at the time of the previous surgery, can also be a source of persistent pain and instability.

Either an open or arthroscopic approach for revision surgery can be used to address recurrent instability; however, scarring and disruption of normal tissue planes can complicate an open revision. If an open approach is chosen, an initial arthroscopy can be beneficial. The posterior and superior labral attachments should be evaluated. Although the surgical approach for open revision stabilization is the same as previously described, the separation of the capsule from the subscapularis is inherently more difficult. The Bankart lesion, if present, is repaired and a capsulorrhaphy to eliminate capsular redundancy is performed.

The ability to visualize and address all intra-articular structures makes the arthroscopic approach desirable for revision surgery. If a nonanatomic open technique such as a coracoid transfer (Bristow) had been used, the alteration in the normal anatomy makes the arthroscopic approach much safer than revision open surgery. The arthroscopic surgical technique is the same as previously described. If posterior or inferior capsular laxity is present, it is addressed prior to the anterior structures. The posterior labral repair is well described in Chapter 19. If a capsulolabral injury is present, it is repaired in the same fashion as the primary injury. The anteroinferior capsulolabral complex is completely separated from the glenoid. If hardware is exposed or if it obstructs appropriate placement of new anchors, an attempt can be made to remove it. In most cases, the new anchors can be adequately placed without undue difficulty. The anteroinferior capsule is incorporated into the labral repair as previously described to effect a reduction in the capsular volume.

Complications

Arthroscopic stabilization is a technically demanding procedure. The surgeon should be well versed in shoulder arthroscopy, be knowledgeable about the arthroscopic equipment, and ideally have a well-trained assistant prior to embarking on this proce

Shoulder Stabilisation Radiograph

Figure 18-16 A and B, Anteroposterior and axillary lateral radiographs of a shoulder with metal suture anchors (arrows) placed too far medially. The patient developed recurrent instability and required revision stabilization.

dure. Because of the learning curve associated with arthroscopic stabilization, a surgeon should have a low threshold for converting to an open shoulder reconstruction if satisfactory repair is not achieved. Prerequisite arthroscopic skills include the following: (1) ability to visualize an instrument from anterior and posterior portals, (2) ability to shuttle and pass monofilament and permanent braided suture, and (3) arthroscopic knot tying.

The complications associated with arthroscopic stabilization include not only problems associated with the actual performance of the steps required to repair the injured tissue, but also include problems associated with the equipment required to maintain adequate visualization during the procedure. The camera, monitor, and arthroscopic equipment may malfunction.

Replacement parts should be readily available to allow continuation of the procedure.

Complications associated with either technique include inadequate tissue preparation leading to an inability to properly mobilize the capsulolabral complex. Inadequate tensioning of the capsulolabral complex can lead to suture breakage or recurrent laxity in the tissue. This may lead to an inadequate repair and surgery failure. Metallic anchors, if left protruding above the articular cartilage, can result in disastrous consequences for the humeral articular cartilage. Even slight prominence can result in a destruction of the humeral cartilage as the shoulder abrades on the metallic edge. Additionally, improperly placed metallic or bioabsorbable anchors can dislodge and become loose bodies that result in destruction of articular cartilage. Some bioab-sorbable fixation devices have been associated with a reactive synovitis as they are hydrolyzed. This may be manifested clinically as an increase in shoulder pain at 4 to 6 weeks postopera-tively and a loss of glenohumeral motion.

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