Open Bankart Repair: Is It Still Relevant?????

Chicago Sports Medicine Symposium 2016

Open Bankart Repair: Is it Still Relevant?????

Brian R. Wolf MD MS Congdon Professor and Vice-Chair of Orthopaedic Surgery Director of Sports Medicine Head Team Physician, University of Iowa, Iowa City, IA

Photos B. Wolf personal file

Disclosures

. No Disclosures relevant to this presentation . Grant support: OREF, Arthrex, Smith and Nephew . Consultant: ConMed . Editorial Board:  Orthopaedic Journal of Sports Medicine . Committees:  Program Committee: ASES, AOSSM, MAOA  Corporate Relations Committee: AOSSM  BOS Fellowship Match Committee Chair: AAOS (chair)

DISCLAIMER

. I do the vast majority of my Scope instability surgery repair DTA arthroscopically . I also do a fair amount of glenoid bone restoration (Latarjet) procedures Open . I absolutely think there is a Bankart role for Open Bankart Repair surgery

1 Open Repair – where did it go?

. Limited exposures in training . Less frequently done . New trend in shoulder instability  Option A: scope repair  Option B: latarjet or bone procedure  WE ARE FORGETTING GOOD INTERMEDIATE OPTION – OPEN REPAIR

The reality

. The majority of primary instability surgery today is done arthroscopically  MOON shoulder data  94 % done arthroscopic (604/640)  2/3 of revision surgery done open

 Latarjet > open Bankart / shift

Anterior instability surgery Proper Preoperative Planning – Evaluate Glenoid Bone Loss X-ray, CT with 3D recons, +/- MRI arthrogram; +/- Arthroscopy

0 to 15% 15% to 25% > 25% Primary Repair Primary Repair OPEN bone (Scope or open) (Open or Scope) Augmentation •Incorporate Any Bony •Incorporate bony procedures Fragments if possible fragments if possible •Liberal use of anchors •± bone augmentation •+/- address Hill Sachs

What was the prior procedure?

Consider different technique for revision 6

2 Glenoid Track – Yamamoto 2007

. Articulation area on humeral head in ABER . If medial edge of HS extends medial to track – risk of engaging  18.4 +/- 2.5mm from edge of cuff  ~16-17 mm from edge of articular cartilage  84% +/- 14% of glenoid width + any glenoid bone loss Images Yamamoto et al JSES 2007

Other Factors affecting Decision

. Age and Activity Level . Revision Setting:  More aggressive in  What was the prior younger and more active procedure? patients  Consider different . Contact sports / Job technique for revision . Ligamentous Laxity  Open allows direct capsular shift  Rotator interval closure

Factors that may push me to do open Bankart Repair

. Hyperlaxity  Tensioned vest over pants capsule vs. plication . Low level bone loss in contact athlete  <15% range on glenoid  Often easier to repair bony Bankart open

3 What’s the Data?

Systematic Review - Brophy, Marx Arthroscopy ‘09

What’s the Data?

Systematic Review - Brophy, Marx Arthroscopy ‘09

. 103 patients, ave age 20 years  Bone loss determined at arthroscopy

 27% engaging Hill Sachs

 4% >20% bone loss on glenoid  2% recurrence  Bone loss not significant predictor

4 Why consider open revision? **Results of revision surgery:

. Open Revision Series:  Sisto AJSM ’07

 0/30 recurrence  Cho AJSM’09

 3/26 (11%) recurrence  Neviaser J Shoulder Elbow Surg ‘15

 0/30 recurrence at 10 years

Why consider open revision? **Results of revision surgery:

. Friedman et al, Arthroscopy ’14, systematic review 388 patients  Arthroscopic revision: 14.7% recurrence  Open revision: 5.5% recurrence  Bristow / Latarjet: 14.7% recurrence

Why consider an open revision?

. Historically low recurrence rates (0-11%)  Sys rev scope revisions – 12.7% (Abouali) . If arthroscopic repair failed once it may be prudent to do different procedure  (Warren: “don’t just assume you can do better than the last surgeon”)

5 Why consider an open revision?

. Not every revision has significant bone loss

Why consider an open revision?

. Bristow / Latarjet is a difficult procedure -not benign  Greissler et al J Shoulder Elbow Surg ’13, systematic review 1904 shoulders  30% complication rate after Bristow Latarjet

 Recurrent instability 9%

 Non-union / fibrous union of coracoid 9%

 Neurovascular complication 2%

 Average ER loss 13 degrees

Pearls of Open Bankart Surgery

. Need an assistant! - more difficult than arthroscopic . Exposure: I am a proponent of subscapularis tenotomy  Upper 2/3 - allows optimal visualization  Need meticulous closure of subscapularis

 interrupted modified Mason Allen sutures using #2 suture

 running size 0 absorbable

6 Advantages of Open Bankart

. Can mobilize capsule from subscapularis and tension / shift appropriately . Direct treatment of rotator interval as needed . Capsule can be overlapped (vest over pants repair) - potentially double the thickness . Can directly repair some bony lesions on glenoid

Subscapularis debate…

. Can do through subscap split if wanted . Outcome directly linked to strength and function of subscapularis- (Sachs et al AJSM ’05) . Shoulder strength slower to return after open repair BUT NO DIFFERENCE at one year - (Rhee et al AJSM ’07) . Randomized trial scope versus open - no difference in strength and subscapularis function at 2-3 years (Hiemstra et al AJSM ’08)

Technique

. Lateral capsulotomy  Can repair later with anchors or tissue to tissue . Mobilize capsulolabral tissue for anatomic repair . Suture anchor on anterior edge of glenoid

7 Technique

. Mattress suture configuration - sutures tied outside capsule - eliminates medial recess of anterior capsule . Position arm appropriate for capsule repair (30/30/30)

Repair Capsule / Subscap

. Can tension capsule as needed . If tenotomy- crucial to have outstanding subscapularis repair

Rehabilitation

. Sling immobilization for 4-6 weeks  Pendulums early to avoid stiffness  Protect subscapularis for 6 weeks - no ER past 0-30 degrees  Usually progress as fast or faster than arthroscopic repairs

8 Just remember….

. There is another option between arthroscopic repair And ……………..Latarjet . OPEN BANKART AND STABILIZATION!

References:

. Neviaser AS, Benke MT, Neviaser RJ. Open Bankart repair for revision of failed prior stabilization: outcome analysis at a mean of more than 10 years. J Shoulder Elbow Surg. . Friedman LG, Griesser MJ, Miniaci AA, Jones MH.Recurrent instability after revision anterior shoulder stabilization surgery. Arthroscopy. 2014 Mar;30(3):372-81. . Griesser MJ, Harris JD, McCoy BW, Hussain WM, Jones MH, Bishop JY, Miniaci A. Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review. J Shoulder Elbow Surg. 2013 Feb;22(2):286-92. . Cho NS, Yi JW, Lee BG, Rhee YG. Revision open Bankart surgery after arthroscopic repair for traumatic anterior shoulder instability. Am J Sports Med. 2009 Nov;37(11):2158-64. . Hiemstra LA, Sasyniuk TM, Mohtadi NG, Fick GH. Shoulder strength after open versus arthroscopic stabilization. Am J Sports Med. 2008 May;36(5):861-7. . Rhee YG, Lim CT, Cho NS. Muscle strength after anterior shoulder stabilization: arthroscopic versus open Bankart repair. Am J Sports Med. 2007 Nov;35(11):1859-64. . Sisto DJ. Revision of failed arthroscopic bankart repairs. Am J Sports Med. 2007 Apr;35(4):537- 41. Epub 2007 Jan 23. . Sachs RA, Williams B, Stone ML, Paxton L, Kuney M. Open Bankart repair: correlation of results with postoperative subscapularis function. Am J Sports Med. 2005 Oct;33(10):1458-62. Epub 2005 Jul 11.

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