The Open Bankart is Best for the Collision Athlete Theodore F. - PowerPoint PPT Presentation

Orthopaedic Summit Las Vegas, Nevada December 8 th , 2017 The Open Bankart is Best for the Collision Athlete Theodore F. Schlegel, MD UC Health / Steadman Hawkins Clinic – Denver

Disclosures Neither I, Theodore Schlegel, or a family member have relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation as follows:  Available in the course book and on the AAOS website

The Pendulum Has Swung Too Far Arthroscopy, April 2014  Arthroscopic Bankart dominate (90%) treatment for shoulder instability.  The incidence doubled between 2004-2009  Easy, quick and safe…  But - The Simple Arthroscopic Bankart is not without its pitfalls…

Arthroscopic Bankart: “Maybe not as good as think” All Publications since 2010  Recurrence Rates following Arthroscopic Anterior Stabilizations  Age <22, Male, collision/contact sport  Castagna et al, AJSM 2012 – 17%  Castagna, et al, Arthroscopy 2012 - 21%  Procellini, et al, JBJS 2009 - 13%  Van der Linde, et al, AJSM 2011 – 35%  Voos, et al, (HSS) AJSM 2010 – 18% Arciero, et al, AAOS 2015

Open Bankart vs. Arthroscopic meta-analysis Open Bankart  less recurrence  less re-operation  > return to work  > return to sport Lenters, et al, JBJS 2007

Open Bankart vs. Arthroscopic Systematic Review Revision surgery  Arthroscopic: 57%  Open: 19% Harris, et al, Arthroscopy 2013

JBJS 2014  23% scope RR vs. 11% open

But this is for all comers: What about for populations it matters in? Cho NS et al, Arthroscopy 2006  Contact Athletes?  Bankart repairs in 29 athletes  Recurrence rate in collision: 28.6%  Recurrence rate in non-collision: 6.7% Double to triple the rate of recurrence!

Is Arthroscopy = to Open in the Contact Athlete AJSM 2006  Collision athletes treated open vs. arthroscopic, modern techniques (excluded bone loss, HAGL, ALPSA from scopes!)  Best study in the literature on this topic  Scope 25%, Open 12%

Arthroscopic Deal Breaker: Bone Loss Arthroscopy 2000  194 consecutive patients with Bankart Repair  6.5% recurrence without bone loss  67% recurrence with bone loss  Contact athletes with bone loss 89%

Balg and Boileau, JBJS Br. 2007  Quantified risk for scope stabilization  Bone loss contributed to 75% failure in scores >6

What is the Appropriate ISIS Score to Use? OTSR 2010 AJSM 2015  70% failure for ISIS >3  If use ISIS 3 or less - 41% of  4% Failure if ISIS 3 or less population needs OPEN High School Contact Athlete: 3

How much Glenoid bone loss can we tolerate? Qualitative:  “Inverted Pear” (De Beer, Burkhart, Arthroscopy 2000) Qualitative :  21% loss compromised  Stability in a Bankart repair (Itoi, et al, JBJS 2000)

The Future: Tokish, et al, AJSM 2014  “Subcritical” bone loss at 13.5% led to an unacceptable clinical outcome EVEN if the patient did not have recurrent instability  WOSI <13.5% 80%  WOSI >13.5% 52%  Need to reconsider what is considered “critical” bone loss

There are real consequences to failure of a Bankart Procedure…  “It might do fine…”  “even if it does fail,”  “you can always revise it, and get a do over…”

Results of scope revision stabilization  There are real consequences of a failed Arthroscopic Bankart procedure Study Jnl / Yr N Failures Kim, et al Arthroscopy 2002 23 22% Creighton, et al Arthroscopy 2007 18 28% Neri, et al JSES 2007 11 27% Barnes, et al AJSM 2009 16 18%  25% Failure Rate on Average: inferior to primary results across the board!

The Gold-Standard – Open Bankart JBJS, 1978  Carter Rowe had it right in 1978  The Bankart Procedure: A Long-Term End- Result Study  161 patients over 30 years (77% Hill Sachs/73% with glenoid rim damage)  All treated with a “open soft tissue repair”  98% good/excellent results  2% recurrent dislocation rate

In Summary  Less is not always more… arthroscopic stabilization isn’t always the answer  In high risk patients (contact athlete, bone loss), arthroscopic will let you down  In the collision athlete – Open Bankart is the clear winner!