Arthroscopic Bankart Repair Is a Function Selection Patient Indication

CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Number 390, pp. 31–41 © 2001 Lippincott Williams & Wilkins, Inc. Arthroscopic Bankart Repair Experience With an Absorbable, Transfixing Implant 03/25/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XGJiJSDa6kLdjliRzOOsR+bI3gZWJ99pv/KNUfPjA6Y= by https://journals.lww.com/clinorthop from Downloaded Stephen Fealy, MD; Mark C. Drakos, BA; Downloaded Answorth A. Allen, MD; and Russell F. Warren, MD from https://journals.lww.com/clinorthop by 3 BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XGJiJSDa6kLdjliRzOOsR+bI3gZWJ99pv/KNUfPjA6Y= The use of arthroscopic means to address shoul- scribed in 1938. The essential lesion of shoulder instability has provided a technically advan- der instability, as described by Bankart, is tageous way to approach Bankart lesions while thought by many to represent the most com- posing complex questions regarding the specific mon disorder underlying possible causes for indications for such an intervention. A successful shoulder instability.2,19,31 It represents a de- outcome with arthroscopic Bankart repair is a tachment of the labrum and its osseous inser- function of proper surgical indication and patient selection. Several authors have evaluated tion from the anteroinferior glenoid. Reestab- the causes of failure and reasons for success with lishing the structural integrity of the soft tissue the Suretac device. The development of a bioab- to glenoid interface is the paramount objective sorbable repair device at the authors’ institution of the Bankart repair and has an essential role was precipitated by a desire to address and re- in surgery for shoulder stability. Although the pair Bankart lesions arthroscopically while traditional open Bankart repair remains the avoiding the frequent complications associated gold standard in treatment options, continued with the metal staple and the transglenoid suture development of arthroscopic techniques and technique. The Suretac represents the first gen- the development of bioabsorbable implants eration of bioabsorbable transfixing devices. The has made arthroscopy-based procedures for initial objectives of the Suretac device were to labral detachment the treatment of choice at adequately and dynamically tension soft tissue to bone, while providing a bioabsorption profile many centers, including the authors’ center. that mirrored the native healing response. The The advent of arthroscopic means to ad- Suretac device is an appropriate surgical tool for dress shoulder instability has provided a tech- arthroscopically repairing Bankart lesions in a nically advantageous way to approach these on 03/25/2020 carefully selected patient population. lesions while posing complex questions regarding the specific indications for such an intervention. It is clear that a successful outcome Treatment of the Bankart lesion has remained with arthroscopic Bankart repair is a function a controversial topic since it was first de- of proper surgical indication. Patient selection is as important if not more important than surgical technique. Research results previously From the Department of Sports Medicine and Shoulder reported indicate that the ideal candidate for Service, Hospital for Special Surgery, affiliated with Cornell University Medical Center, New York, NY. arthroscopic Bankart repair is one who has in- Reprint requests to Stephen Fealy, MD, Hospital for Spe- stability attributable to a discrete Bankart le- cial Surgery, 535 East 70th Street, New York, NY 10021. sion without concomitant capsular laxity or in- 31 Clinical Orthopaedics 32 Fealy et al and Related Research jury.4,29,30,32,35 These authors report that open of failure using arthroscopic techniques were Bankart repair is more appropriately indicated consistently higher than those produced using for patients in whom there is a need for ante- open techniques, although open rates of recur- rior and/or inferior capsular shift and patients rence have been documented to be as high as who have generalized capsular laxity in addi- 37% in one study.16 tion to the presence of a discrete Bankart lesion. Open stabilization procedures generally Development of Suretac have failure rates less than 10%.7 Capsular The development of a bioabsorbable repair de- laxity can be addressed easily with open pro- vice at the authors’ institution was precipitated cedures. Conversely, the prospect of treating by a desire to address and repair Bankart lesions these injuries with decreased morbidity, pain, arthroscopically while avoiding the frequent recovery time, and improved cosmesis has complications associated with the metal staple made arthroscopic Bankart repairs an attrac- and the transglenoid suture technique. The tive alternative. There have been several re- Suretac (Acufex Microsurgical; Mansfield, ports that recognize that open techniques can MA) can be placed arthroscopically without an produce a consistent low rate of recurrence, accessory incision and avoids the technical dif- but these authors have observed a loss of mo- ficulty associated with arthroscopic knot tying. tion (particularly external rotation).6,7,9,11 A Initially, metallic implants were chosen to slower and less consistent ability to return to achieve the necessary soft tissue to bone fixa- contact sports such as football also has been tion arthroscopically. This intervention in- documented.4,7 This observation calls into cluded the use of screws, staples, pins, and consideration the role of arthroscopic over other devices. However, complications arose in open repair of Bankart lesions for athletes who the form of loosening, migration, breakage, participate in contact sports. The nature of cer- joint impingement, articular cartilage damage, tain sports, rather than surgical technique, is and incidence of pain caused by the implant. responsible for recurrence of instability after Reports of recurrence of instability after arthro- arthroscopic and open techniques have been scopic stapling ranged between 3% and 33%.7 used. Poor positioning and subsequent movement Several authors have compared open results and fatigue failure of the metallic staple were with arthroscopic Bankart repair results; the responsible for the high rates of failures with current authors will discuss the outcomes of this device. It is this particular complication these studies below. Arthroscopic treatment of that provided the impetus to design biodegrad- the Bankart lesion has been addressed techni- able fixation devices for orthopaedic proce- cally with repair using metallic staples, trans- dures on the shoulder.12,28 glenoid sutures, bioabsorbable repair devices, Transglenoid sutures seemingly provided and arthroscopically-placed sutures and knot- an attractive alternative to leaving a perma- less anchors. Arthroscopic repair of Bankart le- nent device in the shoulder. However, the sions, regardless of technique used, has been technique initially required an accessory pos- consistently associated with more benefits than terior incision and carried an associated risk of open technique. Patients who undergo arthro- neurovascular injury.20,26 In addition, the pro- scopic Bankart repair experience less surgical cedure bears a risk of articular cartilage injury morbidity, have better range of motion (ROM), because of transscapular drilling. Failure rates and have quicker return to full function than of transglenoid suture repair have been re- those who undergo open procedures. However, ported between 0% and 44%.7 O’Neil20 re- despite the variety of arthroscopic options to cently reported his experience with arthro- address Bankart lesions, several studies have scopic Bankart repair using a transglenoid reported higher rates of failure postoperatively technique in which suture knots were tied pos- than after open procedures.1,7,11,21 Initial rates teriorly on the scapular neck and not through Number 390 September, 2001 Arthroscopic Bankart Repair 33 a separate incision. All patients who were trimethylene carbonate and glycolic acid in a treated had recurrent, unidirectional, anterior reaction initiated by diethylene glycol and cat- instability with an isolated detachment of the alyzed by stannous chloride dihydrate. The labrum. Six patients had a bony Bankart le- chemical formula is indicated below with a ra- sion, which was associated with a decreased tio approximately 67.5 X and 32.5 Y. ROM and strength at a mean of 52 months (CH2COOCH2COO)X postoperatively. Ninety-five percent of pa- Glycolide Moiety tients reported a favorable outcome, and two patients who had an American Shoulder and (CH2CH2CH2OCOO)Y Elbow Surgeons score less than 80 partici- Trimethylene Carbonate Moiety pated in contact football and had reported The compound is metabolized by hydroly- episodes of subluxation. sis and its byproducts are excreted through The arthroscopic staple and the transgle- normal biologic pathways. It is essential to noid suture technique lacked the properties to keep the Suretac device dry and sealed until provide minimally invasive, yet adequate surgery, because exposure to humidified air strength to oppose soft tissue to bone. A new may begin the hydrolysis process. 1 device designed for the specific purpose of The device loses ⁄4 of its strength each limiting morbidity was needed. This device week, until 4 weeks when the device no longer hopefully would provide a similar bioabsorp- plays a mechanical role (Fig 1). The tack has tive profile to that of healing tissue. As the in- a mean bending strength of 23.6 kg

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