Bankart Lesion of the Shoulder

Jocelyn Wittstein, MD
Duke University Medical Center
NC Medical Society Sports Medicine
Symposium July 8, 2006
Case Presentation
• 21 yo Duke defensive back
• Anterior dislocation of L shoulder
4/2004
• Treated with wedge brace with 30º ER x
3 weeks
• Several recurrent subluxations, but able
to make All ACC
• 2nd dislocation 7/2005 when defending a
pass w/shoulder abducted in ER
Case Presentation
• PMHx: unremarkable
• No medications
• Social Hx: Duke student, denies EtOH, tob
Case Presentation
• Physical Exam
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Mild TTP anteriorly
Passive ER 75º at side
Positive apprehension test
SILT
5/5 strength throughout
Importance of lateral views
4/2004
7/2005
Surgery 11/2005
• EUA
– 2+ anterior
– 1+ posteior
– 1+ sulcus
• Arthroscopy
Arthroscopy
TUBS
Traumatic
Unilateral
Bankart lesion
Surgery
Multidirectional Instability
Atraumatic
Multidirectional- Redundancy of IGHLC,
capsular laxity
Bilateral
Rehab
Inferior capsular shift
History
• Hippocrates, 400 BC
• Perthes, 1906
• Bankart, 1939
– 27 traumatic dislocations
– Drill holes through glenoid and suture
– No recurrence
– All with FROM
Epidemiology
• Atraumatic instability is most common in
the second decade of life
• Traumatic instability is most common in
the third decade of life
Etiology
• Traumatic - Bankart
lesion
• detachment of
anterior capsulolabral
complex from the
glenoid rim
• leads to recurrent
anterior instability
HH
G
Shoulder Arthroscopy,
Tibone et al 2003
Recurrence
Rowe JBJS 1956
• 500 shoulders treated for dislocation
• 313 follow up, mean 4.8 years
• incidence of recurrence
– <20yo - 83%
– 20-40yo - 63%
– >40yo - 16%
• age at time of initial dislocation is the
most significant prognostic factor
Natural History
Taylor et al AJSM 1997
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116 young(<24yo), first time dislocators
arthroscopic vs nonoperative
63 chose arthroscopic
97% with Bankart lesion
90% Hill-Sachs, no rotator cuff tears
90% non-op developed recurrent
instability
Associated Injuries
Hawkins JBJS(B) 1982
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Prospective, 40 pts with ant dislocation
ages 40-83
avg. f/u 33 mos
36/40 major RC tear
6/40 brachial plexus injury
Circumferential Injury
• Speer et al (JBJS Am 76:1819-1826,
1994)
– simulated Bankart lesion alone could not
create significant increases in translation
– plastic deformation of the anterior and
posterior capsule may contribute to
instability
Anatomy
• Static factors
• Dynamic factors
Static Factors
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Articular version
Articular conformity
Glenoid labrum
Capsuloligamentous structures
Negative intraarticular pressure
Glenoid Labrum
• Fibrous ring attaching to the glenoid
articular cartilage
• long head of biceps blends with superior
labrum
• IGHL blends into the inferior labrum
Glenoid Labrum
• Deepens the concavity
of glenoid
• Acts as a “bumper”
• Increases the surface
area of contact
• Stabilizing role during
rotator cuff contraction
Cooper et al, JBJS 1992, 74A
Capsuloligamentous Structures
• Superior Glenohumeral and
Coracohumeral Ligaments
• Middle Glenohumeral ligament
• Inferior Glenohumeral ligament complex
• Posterior Capsule
Shoulder Arthroscopy, Tibone et al 2003
IGHLC
• Anterior band
– Resists anterior translation in
abd, ER
• Axillary pouch
– Thinner, acts like hammock
• Posterior band
– acts as a restraint to post
translation in abd, IR
Shoulder Arthroscopy, Tibone et al 2003
Dynamic factors
• Rotator cuff
• Scapular rotators
Rotator Cuff
• Provides dynamic stability by joint
compression
• Prevents superior migration of humeral
head during abduction
Anterior Dislocation
• Humeral head forced out anteriorly and inferiorly
• Capsulolabral disruption
• Hill-Sachs lesion
www.weiss ortho.com
Bankart Lesion
• Traumatic
detachment of the
glenoid labrum
• Seen in over 85% of
cases
• Inferior glenohumeral ligament
injury
Shoulder Arthroscopy, Tibone et al 2003
Bankart Lesion
• Disrupts concavitycompression effect
during rotator cuff
contraction
• eliminates “bumper”
effect
• decreases depth of
socket by 50%
• reduced resistance to
translation by 20%
www.orthop.washington.edu
Patient History
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h/o trauma?
Require reduction?
Voluntary dislocation/reduction?
Shoulder slips? Clicking?
Physical Exam
• ROM (passive and active)
• Cuff strength (RTC tears 90% >40 yo)
• Neurovascular (axillary nerve injuries in
9.3%; all recovered)
– Gumina et al, JBJS Br. Vol 79(4), pgs.540-543, 1997)
• Hyperlaxity testing
• Provocative testing
Hyperlaxity Testing
• Generalized laxity
• Drawer test
• Sulcus sign
Orthohyperguides.com
Drawer Test
Shoulder Arthroscopy, Snyder 2003
Sulcus Sign
Shoulder Arthroscopy, Snyder 2003
Apprehension/Relocation
Test
Shoulder Arthroscopy, Snyder, 2003
Imaging
• Plain films
– AP, scapular Y, axillary view
– Stryker notch view
– West point view
Shoulder Arthroscopy, Snyder
2003
Stryker Notch
View
-FF 135º
-cant beam 45º
cephalad
-demonstrates
Hill-Sachs lesion
Chen et al, AJSM 33 (6), 2005
West Point View
-prone
-shdr elevated 8 cm
-beam canted 25º
medially and
superiorly
-glenoid rim fxs
Chen et al, AJSM 33 (6), 2005
MRI/MRA
Hill-Sachs
Imaging- CT
-useful in
determining size
of glenoid defect
Chen et al 2005
Nonoperative Treatment
• Activity Restriction
• NSAIDs
• Physical Therapy
• Rotator cuff strengthening
• Periscapular strengthening
• Immobilize in 30º of ER
Ancient Methods of Shoulder
Reductions
Traction/Counter Traction
Stimson
Maneuver
• A favorite in EDs
Staso Technique
Reducing Shoulder Dislocation
• Milch technique
Reduction under GA
Nonoperative Treatment
Itoi et al, JBJS 2001
• Immoblization in 30º ER coapts labrum
Conservative RX with ER Brace
Brace for Sports
• Prevents Abduction
• Prevents ER
• Repair after season
Surgery
• Goals:
• Reattach labrum to glenoid rim
• Address capsule laxity if present
• Reconstruct glenoid defects >20%
• Reconstruct Hill-Sachs lesion (allograft, muscle
tendon transfer) if involves >30-50%
Nonanatomic open repairs
• 1940, Magnuson-Stack procedure
• 1948, Putti-Platt procedure
– Loss of ER, capsulorrhaphy arthropathy
• 1956, Dutoit staple capsulorrhaphy
– Staple migration, recurrence, OA
• 1958, Bristow procedure
– 71% with OA at 20 yrs (Singer et al JBJS B 1995)
– 85% w/o recurrence at 26 yrs (Schroder et al AJSM 2006)
Open Bankart Repair
• Avulsed capsule is attached back to the
glenoid rim
– Sutures
– Suture anchors
• +/- Capsular imbrication
Bankart Procedure
Rowe et al JBJS 1978
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145 pts with recurrent anterior instability
86% traumatic, 14% atraumatic
open Bankart repair
avg. f/u 6yrs
5 recurrences(3.5%)
97% good or excellent results
Open Repairs
• Disadvantages
– Blood loss
– Surgical time
– Infection
– Loss of external rotation
Arthroscopic Repair
• Transglenoid sutures
– Risk suprscapular nerve injury
• Tacs
– 6% reabsoprtion synovitis
• Suture Anchors
Arthroscopic Repair
Shoulder Arthroscopy, Tibone et al 2003
Arthroscopic vs. Open repair
w/suture anchors
Fabbriciani et al, Arthroscopy 20(5), 2004
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Randomized, prospective
30 arthroscopic, 30 open
Mean age 25, 26
Similar time to surgery after traumatic dislocation
2 yr f/u
No recurrence in either group
Open group w/significantly less ER
4-9 yr f/u of Open Bankarts
Mangnusson et al AJSM 2002
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47 shoulders s/p open repair
Ave age 25
Mean f/u 69 months
7º ER lost vs nonop side
11% w/recurrent dislocation
Shoulder Arthroscopy,
Snyder 2003
• Why Arthroscopic?
– decrease in surgical time
– decrease in blood loss
– smaller incision
– less loss of motion
– better visualization of pathology
OPEN VS ARTHROSCOPIC REPAIR
What does it cost and how effective is it??
F/U 14 – 31 MONTHS
• ARTHROSCOPIC
• OPEN
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(Panalok + Knotless)
Avg. age = 36 yo.
1/18 recurrent instability
Regional ISB in all
17/18 home same day
Surgical time = 66 min.
Total O.R. time = 83 min.
O.R. charges = $4506
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Bankart through drill holes
Avg. age = 23 yo.
1/18 recurrent dislocation
General anesthesia in all
All 18 stayed overnight
Surgical time = 96 min.
Total O.R. time = 129 min.
O.R. charges = $4550
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Total Hospital charges = $ 6609
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Total Hospital charges = $8192
Warner and Zarins, MGH
Who Should Be Stabilized
Arthroscopically?
• Ideal patient
– Traumatic anterior instability
– Thick, mobile Bankart
– Little of no discernable capsular
laxity
Who Should Be Stabilized
Arthroscopically?
• Contraindications
– Large Hill-Sachs
lesion
– Moderate Glenoid
defects (>20%)
– Contact athletes?
– Marked anterior
laxity
– Poor quality of
ligamentous
structures
Summary
• Traumatic shoulder instability typically
occurs in 3rd decade
• <40 yo: dislocationBankart lesion
w/recurrent dislocation
• >40 yo: recurrence unlikley, cuff tears
common
• Treatment: open vs arthroscopic Bankart
repair