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. Thank you [email protected] 9.