CLINICALORTH]PAEDICS AND RELATEOFESEARCH Number390,pp. 31-41 @ 2001 LippinconWilliams & Wilkins, Inc. ArthroscopicBankart Ilepair ExperienceWith an Absorbable,Transfu;ing lrnplant Stephen Fealy, MD; Mark C. Drako,s,BA; t Answorth A. Allen, MD; and Russell F. Vlarren, MD I I The useof arthroscopicmeans to addressshoul- scribedin 1938.:rTheessential lesion of shoul- der instability hasprovided a technicallyadvan- der instability, as describedby Bankart, is tageousway to approach Bankart lesionswhile thoughtby many to representthe most com- posing complex questions regarding the specific mon disorderunderlying possible causes for indicationsfor suchan intervention. A successful shoulderinstability.2'le'31 It represents a de- outcomewith arthroscopic Bankart repair is a tachmentof the labrumand its osseousinser- function of proper surgical indication and pa- glenoid. tient selection.Several authors have evaluated tion from the ant.eroinferior Reestab- the causesoffailure and reasonsfor successwith lishingthe structural integrity of the softtissue the Suretacdevice. The developmentof a bioab- to glenoidinterfrrce is theparamount objective sorbablerepair deviceat the authors'institution of the Bankaltv6rpair and has an essentialrole rvasprecipitated by a desire to addressand re- in surgeryfor sh,rulderstability. Although the pair Bankart lesions arthroscopically while traditional open Bankartrepair remains the avoiding the frequent complicationsassociatecl gold standardin treatmentoptions, continued rvith the metalstaple and the transglenoidsuture developmentof arthroscopictechniques and technique.The Suretacrepresents the first gen- the developmenr:of bioabsorbableimplants erationof bioabsorbable transfixingdevices. The has made arthrcscopy-basedprocedures for initial objectivesof the Suretac deviceryere to labral detachmelrtthe treatmentof choice at adequatelyand dynamicall_r'tensionsoft tissue to bone, lvhile providing a bioabsorption profile manycenters, inr:luding the authors' center. that mirrored the native healing response.The The adventof arthroscopicmeans to ad- Suretacdevice is an appropriatesurgical tool for dressshoulder instability has provided a tech- arthroscopicallyrepairing Bankart lesionsin a nically advantag,:ousway to approachthese carefullyselected patient population. lesions while posingcomplex questionsre- gardingthe speci[c indicationsfor suchan in- tervention.It is clearthat a successfuloutcome Treatmentof the Bankart lesion hasremained with arthroscopicBankart repair is a function a controversial topic since it was first de- of propersurgical indication. Patient selection is asimportant if notmore important than sur- gical technique.Research results previously From the Departmentof Sportsi\tedicine and Shoulder reportedindicate that the ideal candidatefor Service,Hospital for Speiiat Surgery,affiliated with CornellUnivirsiry Nlediial Center.-Ne* york, Ny. arthroscopicBanllart repair is onewho hasin- Reprintrequests to StephenFeal1.. N.lD, Hospital for Spe- stability attributableto a discreteBankart le- cial Surgery,535 East 70n Street.New yor.li,Ny l00i I . sionwithout conc,cmitant capsular laxity or in- 31 390 Clinical Number Orthopaedics September' 2O0- 32 Fealyet al and RelatedResearch a separateitrt repoft that of failureusing jury.a'29'30':z'3sThese authors open arlhroscopictechniques were treatedhad ret Bankart repair is more appropriatelyindicated consistentlyhigher than those produced using instabilitywitl for patients in whom there is a need for ante- opentechniques, although open rates ofrecur- labrum.Six pr rior and/or inferior capsularshift and patients rencehave been docrmented to be ashich as sion,which w who have generalizedcapsular laxity in addi- 377oin onestudy.r6 ROM and stre tion to the presenceof a discrete Bankart le- postoperativeh Developmentof Suretac sion. Open stabilizationprocedurcs generally tientsrePorted have failure rates less than l0%o.7Capsular Thedeveloprrent of a bioabsorbablerepair de- patientswho h laxity can be addressedeasily with open pro- viceat the authors' inr;titution was precipitated Elbow Sur-eeo cedures. Conversely, the prospect of treating by adesire to addressand repair Bankaft lesions pated in contr theseinjuries with decreasedmorbidity, pain, arthroscopicallyrvhilt: avoidingthe fiequent episodesof sut recovery tinre, and improved cosmesishas complicationsassociated with themetal staple The arthros' made arthroscopic Bankart repairs an attrac- and the transglenoidsuture technique. The noid suturetecl tive alternative.There have beetrseveral re- Suretac(Acufex N4i:rosurgical;Mansfield, provide minirr ports tlrat recognizethat opentechniques can MA) canbe placed afilrroscopically without an strengthto oPP produce a consistentlorv rate of recurrence, accessoryincision and avoids the technical dif- devicedesi,rlnt- but theseautlrors have observed a lossof nro- ficultyassociated rvith afthroscopic knot tying. limiting nrorbi, tion (particularly externalrotation).6'7'e'll A Initially,nretallic irntrrlants rvere chosen to hopefullywoul slower and lessconsistent ability to return to achievethe neccssaryl;oft tissueto bonefixa- tiveprofile to tl contact sports such as football also has been tion arlhroscopically.This interventionin- jured tissueret documented.a'7This observationcalls irrto cludedthe useof scre:rvs,staples, pins, and boneinterface. considerationthe role of arthroscopicover otherdevices. Horvever, conrplications arose irr while sinrultar openrepair of Bankartlesions for athleteswlro the form of loosening,migration, breakage, strengthin an i participatein contactspol'ts. The natureof cer- joint irnpingenrent.artic:ular cartilage danrage, limit thecontpl tain sports,rather than sur,gicaltechnique, is andincidence of painc:aused by the implant. manenceof the responsiblefor recurrenceof instabilityafter Reportsof recun'enceof instability after arthro- arthroscopicand open techniqueshave been scopicstapling rangcd between 3Vo and33Vo.l Scienceof the used. Poor positioningand subsequentntovement Device Severalauthols have compared open results andfatigue failure of the metallicstaple werc The Suretacltr with arthroscopicBankan repair results;the responsiblefor the high ratesof failureswith provide an adc cuffent authorswill discussthe outcornesof this device.It is this parlicularcomplication anteriorshould, thesestudies below. Arthroscopic treatment of thatprovided the inrpetur;to designbiodegrad- the shortcotttittl the Bankart lesionhas been addressed techni- able fixationdevices for orthopaedicproce- four primary in cally with repair using metallicstaples, trans- dureson the shoulder.l2.23 as outlinedby gle,noidsutures, bioabsorbable repair devices, Transglenoidsutures seemingly provided (l) adequate,t and arthroscopically-placedsutures and knot- an attraclivealternative to leavinga perma- strength;(2) a I Iesr;anchors. Arthloscopic repairof Bankarl le- nent devicein the sltoulder.However, the rorsthe healing sions,regardless of techniqueused, has been techniqueinitially requin:d an accessorypos- dynamicfixatio consistentlyassociated rvith rnore benefits than teriorincision and canied an associated risk of profilethat woL' opcn technique.Patients rvho undergo arthro- neurovascularinjury.lo.:0 In addition,the pro- tionin thejoint: scopic Bankart repair experienceless surgical cedurebears a risk of arti<:ularcartilage injury rial thatis meta nrorbidity,have better ran_se of rnotion(ROM), becauseof transscapularclrilling. Failure rates tionswithout ha and have quicker retum to full function than of transglenoidsuture repair have been re- carcinogenic,n tltose rvhoundergo open procedures. However, portedbetneen }Vo and 44Vo.7O'Neil2o re- erties. despite tlre variety of artluoscopicoptions to cently reportedhis expe.riencewith arthro- Polyglyconat Itddress Bankan lesions.several studies have scopicBankart repair using a transglenoid adheremost cl< rcporled hi-qherrates of failure postoperatively techniquein whichsuture l<nots were tied pos- sion criteria. It thun after open procedures.l.T,ll,2lInitial rates teriorlyon the scapularneck and not through ET F i Number390 :al Orthopaedics September,2001 lelatedResearch ArthroscopicBankart Repair 33 a separate incision. All patients rvho were trimethylenecarbonate and acid in a c techniqueswere -elycolic treated had recurrent, unidirectional, anterior reactioninitiated b1'diethylene and cat- 'seproduced using -elycol instability with an isolated detachmentof the alyzed by stannouschloride dihydrate. The penrates ofrecur- labrum. Six patients had a bony Bankart le- chemicalformr,rla is indicatedbelow with a ra- 'd to be as high as sion, which was associatedwith a decreased tio approximately67.5 X and 32.5 Y. ROM and strengthat a mean of 52 months (cH,coocH,coo)x postoperatively. Ninety-five percent pa- of GllcolideMoiety tients reported a favorable outcome,and trvo ;orbablerepair de- (cH,cH,cH,ocoo)Y patients who had an American Shoulderand n'uvasprecipitated Trimetrylene Carbonate Moiety Elbow Surgeons score less than 80 putiigi-- :rirBankart lesions pated in contact football and had reported The compound is metabolizedby hydroly- Jing the frequent episodesof subluxation. sis and its byproducts are excreted through h the metalstaple The arthroscopic staple and the trans_ele- lormal biologic path*'ays.It is essentialto : technique.The noid suturetechnique lacked the propertiesto keep the Suretacdevice dry anclsealed until gical; Mansfield, provide minimally invasive, yet adequate surgery, becaur;eexposure