Name: Arthroscopic Bony Bankart Repair
Uploaded: 2010-09-10T00:00:00Z
Channel: Arthrex

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VID1-003526-en-US | A | Arthroscopic Bony Bankart Repair

Stephen S. Burkhart

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Arthroscopic Bony Bankart Repair

Yeah. I'm going to continue on with arthroscopic bony bankart repair. So if you have bone loss, you can have it obviously on the glenoid side or the humeral side on the glenoid side. The non-inverted pair and the normal pair shape is when you're going to have less than 25% bone loss, then you get the inverted pair. After about 25% bone loss of the inferior glenoid diameter, humeral lesions can be engaging or not engaging. So the normal anatomy, of course, is you've got a pear shaped glenoid here. The inferior part of the of the glenoid is has a radius of about 10 to 12mm on average. And then you have a superior tubercle here. That's probably it's like the world's largest tubercle for the biceps tendon here. So not real sure why it wasn't just a circular joint to begin with. I'm sure that has some physiologic and biomechanical function, but I But I don't really know what that is. Glenoid pathology. You can get this inverted pear. You can have a bony bankart lesion here, this acute glenoid fracture. Or you can get these erosive compressive defects like this one on the right. But these obviously are different animals here. You have to treat them differently. And that's one of the things we're going to talk about in this in this presentation. So what you want to do on something like this, it depends on the size of it. You may want to put some suture anchors and then lasso this thing around or through and reconstruct it like so. Or if it's bigger you may want to use some screws, which is another technique we'll show you. Sugaya in Japan had 100 patients with unilateral traumatic instability that he reported on, evaluated by 3D CT scan. And he found that half of them, 50%, had bony bankart lesions. Fortunately, not a lot of them were large, just largest 1%. But when you get into the medium and small ones, it's a significant amount. And then 40% had erosive lesions. So you're dealing with bone loss 90% of the time of one type or another. And you have to decide how important is it and how do you address it. So you can look at it preoperatively you can address it obviously with x rays. And when you have these really big ones like this lateral posterolateral flattening here, you know that that's almost for sure going to be a ladder shape. The CT scans are good. Mri is not as good for evaluating the bone. The 3D CT scan is the best of all. You can get these on face views like this subtracting out the humerus. And that's probably the best of all. And you can actually quantify how much bone loss you've got. Arthroscopic assessment. It's good to view through an antero-superolateral portal. And you can see the bare spot of the glenoid. And you can actually measure the bare spot should be at the center of center of the glenoid, and you could get a percentage bone loss of that inferior diameter that way. What if you have small lesions? Less than 5%? Such a small amount of bone, there's really nothing to fix. And you can either excise it or just ignore it. Incorporate it into your bankart repair. But just a standard arthroscopic bank card is fine with these. Now you get a little bit larger. These medium lesions 5 to 25% as you get up close to 25%. As Alan was telling you, that's more potentially dangerous situation for failure. And you need to think about reconstructing the bone loss and doing a bony bankart repair. And this is where you'd want to do an anchor repair. You need a minimum of 3 or 4 anchors. You need one above and one below the bone fragment. And then 1 or 2 through the bone fragment or below it. So I'll show a couple of ways that you can repair this, but these sutures can either come through the bone or they can wrap around the bone, depending how big the fragment is now when you place your anchors, if you're going to wrap around the bone, and particularly you don't want for a number of reasons, you don't want to put your anchors on the articular surface. Like Alan said, nothing's going to heal the articular cartilage, so why put it out there? If you do put it a couple of millimeters out? I like to take a thin strip like he showed so that you can get it to heal, you know, a couple of millimeters of of bare bone here. But with these bony bank arts, the biggest thing is, is if you place your anchor out onto the face and then you loop it around that bone fragment, you're going to displace your fragment. So it's going to be very non anatomic. So this is where you want to put it at the edge of the bone cartilage junction basically. So you know a couple of ways you can do it. You can encircle the fragment. And that's probably the probably the most common way, using something like a SutureLasso to do that. Or if there's large mediolateral distance, you may want to go do a trans osseous suture passage and actually go through the bone. That's a little more difficult depending on how hard their bone is. But these are a variety of instruments. You can use a SutureLasso the BirdBeak there's the sidewinder. That's not a common instrument that Arthrex has, but I use it quite often in these. And you can has kind of a sharp tip that you can bore through, but you have to be careful about commuting this fragment. Greater than 25%. This is basically a glenoid fracture. And these generally unless they're comminuted you can fix these with screws. And I'll show you an arthroscopic way to do that too. So these large fragments on the acute bony bank arts we fixed with screw fixation usually, and the smaller ones, suture anchor fixation. This was a case I did probably about 15 years ago. It was just a free hand arthroscopic fixation of a large fragment using the synthes screws. And the problem is, if you've never done that, they have very flexible K-wires. And they also have a very short screwdriver that if you have a patient with very big muscles or a fat patient, your screwdriver screwdriver is too short to do it. Arthroscopically. So this was just the right patient to do this in. Also, where do you do you elevate up the capsule or what? In this case, a lot of people will have this kind of big capacious sulcus anteriorly. And this guy did. So you can put your screws down and leave them intra-articular sitting out there on top of the capsule. You can't always do that, as I'll show in the next case that I show you the. The angle is important too. You have to angle from lateral to medial somewhat, but the glenoid narrows down pretty rapidly in front. It has a very sharp angle. A very sharp angle. Going kind of from anterior to posterior pretty quickly. So if you angle down more than about a 30 degree angle, then you're not going to catch the main body of the glenoid. So you just have to be cognizant of that. And then it's nice to put a suture above and suture below if you can, just with suture anchors to augment it. This is a set that you can look at in the lab today, the glenoid bone loss set. It's actually in conjunction with the latter set. It has these long nesting drill guides. So you can do percutaneous screw fixation. By nesting I mean that it has you have a big cannulation here for drilling. You have a well you have a nesting guide which is a cannula within a cannula. So these fit inside of here. So you have that in there. Initially you put your car in, then you take it out and then you drill and then you'll take that out. And then you put your, your screw in. So and you see the screwdriver is quite long. It does have a measurement system. It has these non-threaded K-wires so that you can feel when you hit the far cortex and go through that. And then their measuring system puts you five millimeters from the end of your K-wires so that. Anyway, I think it's worthwhile for you to look at if you're interested in this. So this is a case of arthroscopic reduction internal fixation of a large glenoid fracture. So we're looking from an antero-superolateral portal. And this is a right shoulder. So this is anterior. And when you first look at that you can't really tell until you investigate these. It looks almost two comminuted to fix. So I initially was thinking well this is going to have to be a lighter shade to stabilize them. But then you have to play with it. This is just a little prototype elevator. We had to sort of lift it up and see what is happening here. And after we get all that clot cleared out, it's starting to look like maybe we can do something. This is one you always have to release a little bit of soft tissue on the upper and lower borders of these, but this is one that didn't have that big anterior sulcus. So the screw heads could be a problem if you don't release some of that capsule. But yet but yet you don't want to release it all, or else you'll devitalize that fragments. I'm releasing a little bit here, so I'll have a place for the screw heads to go and just want to get my angle of approach. This is where you have to go through the sub scap through a 5:00 portal. Unfortunately, you only have to go with the nesting guys. You don't have to put a big cannula in there. These will be 3.75mm screws 2.7 drill drill rather. So you can use an elevator to provide some counter pressure while you get that started. We've got probably 20 degree angle of approach or thereabouts. If you get too much, you'll miss the main glenoid going in. So now I'm just pushing it up top and getting our reduction. That's pretty smooth there. But then this is one that looked like it was going to be too comminuted for screws. But then if you play with these you can see a lot of times they're not. So you'll see I was it wasn't a real big fragment. It was kind of it was it was afraid if I went any lower, I wouldn't catch the glenoid. So I had to have the screw head up a little bit high. And so I had told the patient, if we put the screws in, we'd probably have to come back in six months and take them out. And obviously with the screw head there, I'm going to come back and take it out at about six months, and I recess it as much as I can. But you don't want to come in with your fragment. But you see, we've got very nice matching surfaces here that the level of the fragment is the same as the level. Now here you can use your little suture retriever to put the guide pin where you want it. So that's kind of a little trick that you can use. So we get this one up a little bit higher. And then I'm just going to hand spin this because I'm afraid it's getting a little close to the edge. So I'll hand spin this drill just to get through the near cortex so I won't accommodate it going in. And I debated about using just one screw, but I wanted to have some rotational control. So you just put these in very slowly and forward 90 degrees, backward 45 degrees. And now in this case, if I have prominent screw heads, I like to bring the capsule over, much like we do with the latter, and put the anchors in some anchors into our native glenoid to try to then cover this fragment. Basically cover the screw heads with some padding until I can take the screws out at six months and that's been been successful. It gives you a chance to look and see how it healed too. So here's our final result. So we've got our fragment here. It's covered with this capsule is kind of a pad. So this was not a real easy case. What you want is a nice big single fragment. But you see that this is very nicely centered right over the bare spot of the glenoid. So that's what you want at the end. For a small bone fragment, it's a little bit different. Your end point again is though from this antero-superolateral portal, to have the the arc of your humerus centered on this bare spot, a lot of times these fragments, you can have a fairly big fragment that you don't really see the bone. It's sort of encapsulated within your capsule here. So. Okay. So this is a dominant arm and a baseball player. So I wanted to try to preserve this if I can and I certainly don't want to do in a dominant arm or an overhead athlete. So he had a shallow Hill-Sachs lesion not engaging in 90 degrees in the 9090 position. Here's our antero-superolateral portal. And here's the fragment is within this within this little bubble of capsule here measuring the bone loss. It's a routine thing we do. You have the hash marks on your calibrated probe here, and you can see what the can measure exactly what the bone loss is. Then we'll prepare our anterior gland and all these things that you've heard before. If there's an offset, it's important that you elevate this enough that it all kind of floats up. And then in these, I tend not to take quite. I'm just basically preparing the glenoid anterior glenoid here with that. Curette. Which is a is a very nice instrument. A lot of the if you're going to have to use a 5:00 portal, it's usually going to be on bone loss cases. And so that's what I'm doing here. I'll put a spinal needle in and then I'll come right beside it with just with a spear guide with a sharp trocar in it. And then do my anchor placement. And I'll typically if you need to use at 5:00 portal, you might as well put two anchors through it, your two lowest anchors because it'll give you a real straight shot. And so this you can do any grade you can use. This is a Viper, but you can use a Scorpion down low. If you have a bone loss. Often you'll have enough room to do that. Or you can use a lasso. But what Allen said is true. You need to get now this is that sidewinder. This has you see, it has a 45 degree angle and you can punch through this bone oftentimes, and you just open the tips just enough to do a handoff and get one of those sutures into it. And so if I have a pretty large bone fragment, I'll that's my favorite instrument for punching through the bone. It's a little used instrument for other things, but it's a nice thing to have. And then you just sequentially tie your sutures and it's just a standard repair. And then you put an anchor above at the very top as well. So here again what you want is your endpoint. You want the arc of that humerus to be centered over the bare spot of the glenoid. And then you whatever kind of instability you're doing, you want that to be your endpoint. So chronic bony bankart lesions greater than four dislocations. Usually you're not going to have enough. You're not going to have enough bone to really work with there. It's going to be small and rounded, poor healing potential for the bone fragment. And then that's where you start to think about your bone loss criteria for.

Arthroscopic Bony Bankart Repair

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