The Treatment of Traumatic Recurrent Anterior Shoulder Instability with Arthroscopic Bankart Repair

Transcription

1 J Med Sci 22;22(2): Copyright 22 JMS Hsing-Ning Yu, et al. The Treatment of Traumatic Recurrent Anterior Shoulder Instability with Arthroscopic Bankart Repair Hsing-Ning Yu *, and Tai-Hung Jau Department of Orthopaedics, Armed Forces Tsoying Hospital, Kaohsiung, Taiwan, Republic of China ABSTRACT: Method: From July 1998 to June 2, twenty-five traumatic recurrent anterior shoulder instability cases were collected. These cases were treated with an arthroscopic-assisted Bankart repair fixed with the FASTak suture anchor. There were 23 men and 2 women with an average age of 22 years (range: 19 to 29 years). The shoulder function was surveyed at a mean follow-up of 24 months (range: 14 to 34 months) using the modified Rowe scale. Results: The results were 14 excellent, 9 good, 2 fair, and no poor, for an overall success rate of 92%. The shoulder function improved in 23 of the 25 cases. There were 2 recurrences. Conclusion: Although the early results seem promising, long-term follow up is necessary before this procedure can be used in general practice. Our results suggest that arthroscopic-assisted Bankart repair is an effective treatment for traumatic recurrent anterior shoulder instability. Key words: anterior shoulder instability, Bankart lesion INTRODUCTION Received: September 27, 21; Revised: January 1, 22; Accepted: January 14, 22. * Corresponding author: Hsing-Ning Yu, Department of Orthopaedics, Armed Forces Tsoying Hospital, No. 553, Chun-Hsiao Road, Tsoying, Kaohsiung, Taiwan, Republic of China. Tel: ; Fax: Recurrent shoulder instability has been recognized as a clinical entity in the military and general populations for many years. Theories regarding the etiology of recurrent shoulder instability have evolved considerably in recent years. Many authors pointed out three concepts involving this condition: (1) a labral avulsion popularized by Bankart, (2) muscular insufficiencies described by Magnuson and depalma, and (3) bony abnormalities in the glenoid or humeral head 1. The Bankart lesion has received the most attention. There is however no essential pathologic lesion responsible for every recurrent shoulder dislocation. An understanding of the shoulder anatomy is necessary to explain how the bony anatomy of the shoulder joint does not provide inherent stability. The shoulder is one of the most unstable and frequently dislocated joints in the body 2. According to studies by Turkel et al., the inferior glenohumeral ligament is the primary stabilizing structure in the glenohumeral joint. The anterior labrum is the attachment area for the inferior glenohumeral ligament 3. A complete detachment of the anteroinferior labrum from the bony glenoid rim, called a Bankart lesion, causes a disruption in the integrity of the inferior glenohumeral ligament-labrum complex and can result in instability. As we know, the Bankart lesion is the most significant of the lesions responsible for anterior dislocation 4,5. Many studies have emphasized the importance of the inferior glenohumeral ligament-labrum complex in providing a stabilizing force, especially with increasing abduction 6,7. Because of advanced arthroscopic techniques and equipment, and increased knowledge of the pathomechanics of the shoulder, arthroscopic surgery has become much more common 8-1. Arthroscopic stabilization techniques are technically demanding. The proponents of arthroscopic stabilization cite its advantages as including more accurate identification of intra-articular pathology, decreased morbidity, improved cosmesis, faster recovery and rehabilitation, and diminished postoperative pain. The disadvantages include complications inherent to the technique applied, requisite technical skill, and possibly higher failure rates. The Arthrex FASTak suture anchor system offers an arthroscopic-assisted Bankart repair technique that is simple, less time consuming, anatomic and reproducible. The FASTak suture anchor is a titanium, self-drilling implant (size: 2.4 mm in diameter; 11.7 mm in length) with an eyelet for suture attachment. The 2.4 mm diameter titanium FASTak with size 1 non-absorbable braided polyester suture and cannulated inserter is shown in Fig. 1. Soft tissue positioning and FASTak delivery are accomplished with a patented cannulated grasping instrument that picks up the soft tissue and delivers the anchor through its inner cannulation, through the repositioned soft tissue and into the glenoid bone in one maneuver. 63

2 Anterior shoulder instability with arthroscopic repair radiographic review and clinical examinations. The average number of dislocations was 6 (range: 3-2). The preoperative evaluation included medical history, physical examination, routine plain x-rays, shoulder arthrography plus CT scan (Fig. 2) and modified Rowe scale evaluation (Table 1). We excluded patients with Hill-Sachs lesions from this study using the preoperative CTarthrography. The FASTak suture was routinely used in repairing the Bankart lesions in these patients. All of these patients received a further examination under anesthesia. It was found that their shoulders could be dislocated anteriorly. The operative findings showed a Bankart lesion in 1% of these patients. The mean follow-up was 24 months (range: months). Fig. 1 Cannulated FASTak inserter, FASTak suture anchor with non-absorbable suture. Historically, suture anchors were developed in tandem with arthroscopic procedures about the shoulder as these techniques in orthopaedic surgery became more commonplace. Many studies have focused on the mechanical pullout strength associated with various types of anchors. These studies agree that the strength of the suture anchor is related to the type of bone in which the anchor is placed and is ultimately dependent upon the strength of the suture used with the anchor11,12. Many clinical reports on suture anchors have been related to hardware migration into the joint, incorrect placement of the implant and loosening, or breakage of the device. With the frequency and commonplace use of suture anchors, the significance and number of patients with these problems have been reported13. The purpose of this study is to describe the results of arthroscopic-assisted Bankart repair with FASTak suture anchors. Arthroscopy of the shoulder is a useful tool for the evaluation and management of traumatic recurrent anterior shoulder instability. MATERIALS AND METHODS This study was initiated for all patients with traumatic recurrent anterior shoulder instability that required surgical treatment from July 1998 to June 2. Twenty-five patients were treated with the arthroscopic Bankart repair for traumatic recurrent anterior shoulder instability over this period. All patients were available for follow-up examinations. They were 23 males and 2 females, with an average age of 22 years (range: 19 to 29 years). These patients were identified and evaluated using record and 64 Fig. 2 Bankart lesion in CT-arthrogram. SURGICAL TECHNIQUE After the induction of general anesthesia, the affected shoulder was examined as well as the contralateral shoulder. This examination was performed with the patient in the supine position. The patient was then placed in the lateral decubitus position with the affected side up, prepared and draped in the usual sterile fashion. The shoulder was placed in traction (1-15 pounds) with the arm placed in a position 3 to 7 degrees in abduction and 115 degrees in forward flexion. At the beginning of the procedure, a marking pen was used to outline the bony anatomical shoulder landmarks, mainly the coracoid process, the acromioclavicular joint, the anterior, lateral, and posterior borders of the acromion, and the spine of the scapula (Fig.3).

3 Hsing-Ning Yu, et al. Table 1 Modified Rowe Scale ( From: Lee HM. Modified Bankart reconstruction for recurrent anterior shoulder dislocation-using Mitek GII suture anchors. J Surg Assoc ROC 1997;3: ) A standard posterior portal was located approximately 2 cm inferior and 1 cm medial to the posterolateral corner of the acromion. A spinal needle was introduced into the shoulder joint and 5 ml of normal saline was used to inflate the joint cavity. The arthroscope attached to a video camera was then introduced into the joint with the overhead irrigation fluid connected to the scope. An anterior portal was created by inserting a spinal needle into the intraarticular triangle formed by the biceps tendon, the glenoid labrum, and the humeral head, as described by Matthews. After a thorough examination of the anterior structures from the posterior portal, the arthroscopy was placed in the anterior portal and an examination of the posterior capsule and labrum was performed. The first intraarticular landmark identified was the long head of the biceps tendon. This tendon, which has a round cross section, appears to arise from the labrum and crosses the humeral head to exit anteriorly under the transverse humeral ligament. The inferior glenohumeral ligament, the most important of the glenohumeral ligaments, can then be visualized. After all of the portals were established and all intraarticular structures were evaluated, the detached labrum was noted (Fig. 4) and the anterior glenoid rim and scapular neck were abraded to create a fibroblastic bed with a burr. Using a periosteal elevator, the scapular neck and glenoid rim were dissected to mobilize the inferior glenohumeral ligament-labral complex to reposition the labrum onto the glenoid rim. Through the anterior operative cannula, the FASTak grasper was used to pick up the avulsed soft tissue and repositions or shift this tissue both superiorly and laterally up to the glenoid rim. While maintaining proper Bankart lesion soft tissue positioning Fig. 3 Outline the bony anatomic landmarks about the shoulder and mark the anterior and posterior portals before surgery. Fig. 4 Intraoperative arthroscopic finding: a complete detachment of the anteroinferior labrum from the bony glenoid rim. Assessment Score Function No limitation in work or sport: little 4 or no discomfort Mild limitation minimum discomfort 3 Moderate limitation and discomfort 2 Marked limitation and pain Pain None 1 Moderate 5 Severe Stability Negative apprehension with no subluxation 3 Negative apprehension with pain during 15 abduction in external rotation Positive apprehension with positive sense of subluxation Motion Full 2 Equal to or less than 25% loss in any plane 1 Greater than 25 % loss in any plane 65

4 Anterior shoulder instability with arthroscopic repair against the glenoid rim with the FASTak grasper, the FASTak inserter with the suture-loaded FASTak was advanced through the grasper cannulation through the soft tissue purchased using the grasper and into the bone of the scapular neck using a power drill at low rpms. After the FASTak inserter and grasper were removed from the anterior operative cannula, a vertically oriented suture repair and stitch were created using the 6th finger knot pusher and percutaneous knot cutter (Fig. 5). The entire process used to place the first FASTak was repeated for placing the second FASTak. Following knot tying, a probe was inserted to verify firm apposition of the soft tissue to the bone for the entire length of the repair. If insufficient stability was determined, an additional FASTak could be inserted as indicated in order to stabilize the repair. Postoperatively, the patient wore a sling and swathe continuously for 3 weeks. After 3 weeks, immobilization was discontinued, but patients were advised to wear the immobilizer at night for a total of 6 weeks. Daily pendulum forward flexion and internal rotation exercises were begun at 3 weeks postoperation. Passive and active rangeof-motion exercises, including vertical arm elevation, were started at 6 weeks and full range-of-motion, including external rotation and abduction, should be obtained by 12 weeks. Return to participation in sports was allowed when mobility and strength were recovered after 4 months. follow-up, the painful disability, the recurrence of dislocation, the range-of-motion, and modified Rowe scale were evaluated. With the modified Rowe scale, the results were graded excellent (9 to 1 points), good (7 to 89 points), fair (4 to 69 points), or poor (39 points or less). The average preoperative Rowe score was 45 points (range: 35 to 6). The preoperative grades were 23 fair and 2 poor. The average postoperative Rowe score showed a significant increase to 9 points (range: 65 to 1). Eight patients attained the maximum score of 1 points. The corresponding postoperative modified Rowe grades were 14 excellent, 9 good, 2 fair, and no poor. Two patients suffered recurrent dislocations. No case lost external rotation postoperatively under cooperation with the rehabilitation program. No one developed a wound infection after arthroscopic surgery. Postoperative radiographs revealed no fractures of the glenoid rim related to FASTak suture anchors or evidence of migration or loosening up to the present (Fig. 6). No perioperative complications occurred in the study group. Fig. 6 Postoperative AP radiography showed 3 FASTak suture anchors in the proper position. DISCUSSION Fig. 5 Intraoperative arthroscopic finding: first suture knot was tied and apposed the soft tissue to bone. RESULTS We reviewed the clinical results of 25 patients who underwent arthroscopic Bankart repair for traumatic recurrent anterior shoulder instability. All patients were available for follow-up, which averaged 24 months. At 66 In an effort to treat habitual anterior shoulder dislocation, orthopaedic surgeons have devised more than 15 different operations designed to prevent recurrence. However, there is no single best procedure. Ideally, a successful habitual shoulder dislocation corrective procedure should include low recurrence rate, low complication rate, low reoperative rate, early range-of-motion and rehabilitation program, etc. Successful treatment of shoulder instability should be based on a through understanding of

5 Hsing-Ning Yu, et al. the various posttraumatic lesions that can be associated with a deficient capsulolabral complex and on correct classification of the patient s primary and secondary lesions. Classification and treatment of shoulder instability is based on many factors including the direction, the degree, the patient s age, the site and nature of the damage at the time of the initial dislocation, and associated conditions, such as seizures, neuromuscular disorders, collagen deficiencies, and congenital disorders. Studies by Rowe et al. demonstrated recurrence rates greater than 9% in patients younger than 2 years of age. Age is an important factor in predicting the pathological lesions and outcomes. Our study included 25 patients with an average age of 22 years (range: 19 to 29 years). They had sustained traumatic recurrent anterior shoulder instability with an average recurrence rates of 6 times (range: 3 to 2). The dislocation direction in these cases were classified as anterior (7 cases) and anteroinferior (18 cases). No posterior or superior dislocation cases were collected. No one had a voluntary dislocation after mental status evaluation. There were 2 patients that suffered recurrences who exhibited excessive laxity in the anteroinferior capsule after 2 suture anchor fixations. At that time, a third suture anchor was inserted for additional fixation. Arthroscopic thermal shrinkage modality or open capsulorrhaphy procedures were not applied. Capsular tensioning must be critically analyzed at the time of surgery to prevent recurrence. Hardy et al. suggested that laser-assisted shrinkage of the anteroinferior glenohumeral joint capsule could augment an arthroscopic Bankart repair 14,15. Recently, non-ablative thermal energy was used to shrink the redundant glenohumeral joint capsule in patients with shoulder instability. This procedure has generated a great deal of interest. As we know, the Bankart lesion can be detected easily at the time of arthroscopy. Often unappreciated is the degree of capsular laxity or plastic deformation. Thermal capsular shrinkage may be used as an adjunct to a capsulolabral repair and multidirectional instability Several series have demonstrated that the inferior glenohumeral ligament plays an important role in preventing instability. They emphasized that the inferior glenohumeral ligament, which is attached to the glenoid rim, is the essential structure maintaining anterior stability of the shoulder joint. Most authors believe that the Bankart repair is the standard procedure for traumatic recurrent anterior shoulder instability 5,1,18. In this study, Bankart lesions were noted using preoperative CT-arthrography. The original Bankart repair has been criticized as being technically difficult. Recently, diagnostic and surgical arthroscopy of the shoulder has been become more common as surgeons have developed proficiency with the arthroscopy in the knee and appropriate instrumentation has been developed. Although several authors have reported high recurrence rates with arthroscopic stabilization and failure rates as high as 4% to 5% in several series. A steep learning curve, difficulty evaluating ligament tension arthroscopically, and diminished scarring response are some of the possible reasons for the higher recurrence rates after arthroscopic procedures 1. We noted that the arthroscopic stabilization procedure for anterior shoulder instability offered several advantages over open techniques, including reduced postoperative morbidity and shorter hospital stay, decreased range-of-motion loss, less postoperative pain, improved assessment and treatment of the associated intraarticular pathology, and improved cosmesis 5,1. An arthroscopic evaluation may reduce the incidence of misdiagnosis. The arthroscope is therefore a useful and effective tool for the evaluation and management of anterior shoulder instability. The use of metallic suture anchors about the shoulder is commonplace and useful having been greatly advanced by open or arthroscopic shoulder techniques. There are significant risks if the anchors are placed improperly, as with other hardware used about the shoulder. Complications with screws, staples, and pins in shoulder surgery have been well documented, such as impingement, loosening, or migraion 19. Many available series focused on the mechanical pullout strength associated with the various types of anchors. Clinical reports have involved suture anchors related to anchor placement surgical techniques or reconstruction techniques. We used the FASTak suture anchor, which consists of titanium, self-drilling suture anchor with an eyelet for suture attachment. We believe that these suture anchors allow quick and secure Bankart lesion reattachment for early rehabilitation and can simplify the surgical procedure to shorten operation time. Although the early results are promising, long-term follow up is necessary to determine the effectiveness of this procedure. Our study demonstrated that the arthroscopic Bankart repair with suture anchor is an effective treatment method for traumatic recurrent anterior shoulder instability. REFERENCES 1. Parisien JS, Wolf EM. Arthroscopic capsulolabral repair using suture anchors. Techniques in Therapeutic Arthroscopy. New York: Raven Press, 1993:

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