ARTHROSCOPIC BANKART REPAIR WITH THE SURETAC DEVICE FOR TRAUMATIC ANTERIOR SHOULDER INSTABILITY IN ATHLETES

0030-5898/01 $15.00

REPAIR OF ATHLETIC SHOULDER INJURIES

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ARTHROSCOPIC BANKART REPAIR WITH THE SURETAC DEVICE FOR TRAUMATIC ANTERIOR SHOULDER INSTABILITY IN ATHLETES Brian J. Cole, MD, Anthony A. Romeo, MD, and Jon J. P. Warner, MD

Techniques for the arthroscopic treatment of recurrent shoulder instability have flourished despite a number of early reports indicating greater failure rates compared with traditional open stabilization techniques. Proponents of arthroscopic stabilization cite its advantages, including anatomic repair, lower morbidity, improved cosmesis, faster recovery, and the possibly of better postoperative motion. Disadvantages include complications inherent to the technique applied, requisite technical skill, limited versatility to treat a spectrum of pathology, and generally higher failure rates. Arthroscopic techniques include the 2-pronged metal staple with the inherent risk of loosening and joint-surface injury; transglenoid suturing, which risks injury to the suprascapular nerve and requires a posterior incision; and suture anchors requiring intraarticular knot tying. Recurrence rates following arthroscopic stapling range between 3% and 33%.'-'' Reports of failures after arthroscopic trans lenoid suturing range from 0% to 44°/o?5z-z6Failure rates following arthroscopic placement of suture anchors range between 0% and 33Y0.~'"~ The Suretac device (Acufex Microsurgical, Mansfield, MA) is an absorbable implant that

is placed arthroscopically using a cannulated Although technically easier system (Fig. l)?3,34 than many of the other arthroscopic methods, patient selection is critical. Reports of failures followin its application range from 0% to 21Y0.3~~~' This article reviews the relevant pathoanatomy of traumatic anterior shoulder instability, patient selection, surgical technique, and results of arthroscopic stabilization of the shoulder using the Suretac device. ANATOMY OF SHOULDER STABILITY As summarized by Cole and Warner:9 understanding the static and dynamic stabilizers of the glenohumeraljoint is of primary importance in effectively treating shoulder instability. Relevant to arthroscopic stabilization using the Suretac device is an understanding of the pathoanatomy of the labrum and capsule. The Glenoid Labrum The labrum is a fibrous ring attaching to the glenoid articular cartilage through a narrow

This article was originally published in the July 2000 issue' of Operative Techniques in Sports Medicine.

From the Shoulder Section, Department of Orthopaedic Surgery, Rush-Presbyterian St. Luke's Medical Center, Chicago, Illinois, and the Harvard Shoulder Service, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts ORTHOPEDIC CLINICS OF NORTH AMERICA VOLUME 32 NUMBER 3 JULY 2001

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The Capsule

Plastic deformation, capsular rupture, abnormal laxity, periosteal capsular stripping, or any combination of these lesions may also be associated with anterior shoulder instability. Recurrent anterior dislocation is associated with some amount of capsular deformation or s t r e t ~ h . ' ~ ,Failure ~ ' ~ ~ ~to address the injury to the capsule at the time of arthroscopic repair may ex lain higher failure rates in some series.8.34,5)8.54.55

Figure 1. The Suretac device: see text for additional explanation.

fibrocartilaginous transition zone that creates depth to an otherwise inherently unstable articulation?' The labrum provides an attachment site for the glenohumeral ligaments (GHLs) and the tendon of the long head of the biceps. Its principal function is to increase the depth of the glenoid socket and to act as a "chock-block" preventing the head from rolling over the edge of the glenoid. Most labral lesions are associated with glenohumeral instability, especially those below the glenoid equator where the labrum is normally attached tightly. Perthes41 and Bankart4' (of the PerthesBankart lesion) described the detachment of the capsulolabral complex from the glenoid rim and scapular neck as the essential lesion leading to recurrent anterior dislocation. A Bankart lesion corresponds to detachment of the inferior GHL (IGHL) from the anteroinThis lesion decreases ferior glenoid the depth of the socket by 50% at this site, reducing the concavity of the glenoid rim and adversely affecting the concavitycompression mechanism during rotator cuff contraction, as well as the chock-block effect of the labrum.44 Lazarus et a145 determined that by creating a chondral-labral defect, an 80% reduction in the height of the glenoid occurred with a concomitant reduction in the stability ratio of 65% in the direction of the defect. Isolated detachment of the labrum as a singular entity leading to recurrent instabili has been challenged by several auth0rs.46~' Despite this controversy, the Bankart lesion commonly occurs in up to 97% of first-time traumatic anterior shoulder dislocation^.^^-^^

PATIENT SELECTION General Considerations

The diagnosis of traumatic anterior shoulder instability is confirmed by a thorough history, physical examination, and plain radiographs. Arm position at the time of the initial injury and the method of reduction give clues to the extent of the intraarticular pathology. Multiple recurrences may suggest a higher risk of capsular deformation. Provocative testing for apprehension and the relocation maneuver can also provide a qualitative assessment of anterior shoulder i n ~ t a b i l i t y . ~ ~ Patients with multidirectional instability or excessively lax shoulders are not considered candidates for this technique. Findings on radiographic evaluation, examination under anesthesia, and the pathology identified at the time of arthroscopy are critical to selecting the appropriate patient to treat with the Suretac device. Radiographic Evaluation

Radiographic evaluation using contrastenhanced magnetic resonance imaging or computed tomography of the shoulder may help determine the condition of the labrum and capsule. Those with a discrete Bankart lesion are better candidates for arthroscopic stabilization with the Suretac device. If the pathoanatomy primarily involves the capsule, then alternative techniques should be used. The presence of a large glenoid rim fracture or Hill-Sachs lesion will adversely affect the outcome and prohibits the use of the Suretac device. Large bone defects must be treated directly, or the surgeon may compromise range of motion for stability with nonanatomic tightening of the glenohumeral joint capsule.

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Examination Under Anesthesia

Examination under anesthesia with findings graded as described by Altchek et a157 will confirm the predominant direction of the instability as suspected from the office evaluation, and may suggest lesser components of the instability pattern. A high correlation exists between the findings on examination under anesthesia and the findings at the time of Stabilization Stability is tested in all 3 directions (anterior, posterior, and inferior) using a number of different arm positions of abduction placing different portions of the capsule on tension. General anesthesia and muscle relaxation are important to allow side-to-side comparisons. Patients with pure 2+ or 3+ anterior translation compared with the contralateral shoulder (ie, subluxation over the glenoid rim with spontaneous reduction or frank dislocation over the glenoid rim without spontaneous reduction) are generally considered good candidates for arthroscopic stabilization. Those with a 2+ or greater sulcus sign compared with the contralateral shoulder (ie, an acromiohumeral distance of 1 to 2 cm) in addition to their anterior translation should be carefully evaluated for significant capsular laxity or an enlarged rotator interval. This pathology must be addressed at the time of surgical stabilization. Arthroscopic Evaluation

Diagnostic arthroscopy includes the evaluation of the articular surfaces, the biceps complex, labrum, rotator cuff, capsule, and GHLs. Anatomic lesions such as a detached anteroinferior glenoid labrum, a Hill-Sachs lesion, excessive capsular redundancy, as well as subtle signs of instability, such as labral fraying, can be identified. Ideally, a discrete Bankart lesion (Fig. 2A) without significant fraying or degeneration is most amenable to treatment with the Suretac implant. Patients with pathologic capsular laxity or capsular detachment with or without a Bankart lesion (Fig. 28) are better candidates for alternative arthroscopic techniques or open stabilization. Some authors have suggested that a drivethrough test6' after arthroscopic Bankart repair may indicate residual capsular laxity that should be addressed by thermal, arthroscopic or open means, but in general how much tightening or where to tighten the capsule

Figure 2. Arthroscopic view through the posterior portal (G,glenoid; L, labrum; IGHL, inferior glenohumeral ligament). (A) A well-defined Bankart lesion and (B) a patulous capsule without a Bankart lesion.

remains a decision based on factors determined before the labral stabilization. SURGICAL TECHNIQUE Implant Device and Instrumentation

The Suretac implant is a cannulated bioabsorbable ribbed tack made from the copolymer, polyglyconate. The implant is resorbed over a 24-week period.34 The strength of initial fixation using pullout studies in cancellous bone is approximately 102 N.60However, after 4 weeks of biodegradation, there is nearly 90% loss of strength. Histology at 6 months shows residual polyglyconate polymer with a histiocytic infiltrate and foreignbody giant cells.36 The tack includes a spiked crown head to increase the holding power while minimizing soft tissue necrosis (Fig. 1). The most commonly used implant (8 mm) measures 16 mm

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in length with a shaft and head diameter of 4.2 and 7.5 mm, respectively. The guidewire measures 0.062 15 inches. Smaller implants (6 mm) are available also measuring 16 mm in length with a shaft and head diameter of 3.5 and 6.5 mm, respectively. The guidewire for this implant measures 0.039 15 inches. The instrumentation system is composed of a trocar through which a drill is passed while attached to a drill handle or power drill. The drill bit is cannulated to receive the guidewire that is fixed proximally with a set screw so that the tip protrudes 3 to 4 mm from the end of the drill (Fig. 3). Arthroscopic Evaluation

The authors perform shoulder arthroscopy in the beach-chair position when the procedure is an arthroscopic Bankart repair. The beach-chair position offers the advantages of an easy conversion to an open procedure if necessary and traction devices or special equipment to position the extremity are not required.61 Examination under anesthesia is performed to confirm the diagnosis and assess the restraints to glenohumeral translations. A standard posterior portal is established as are 2 working anterior portals. An anterosu-

perior portal is placed just lateral and superior to the palpable coracoid process so that it pierces the rotator interval capsule and enters intraarticularly at the level of the insertion of the biceps tendon onto the superior labrum. This can be accomplished using an inside-out technique once the posterior portal is established. The cannula should be easily manipulated above and below the biceps tendon. The anterosuperior cannula is used to enhance inflow if no pump is used, or for outflow when a pump is used (Fig. 4A). A second anterior portal is established to receive the 7-mm cannula-trocar assembly. The location of this cannula is inferior to the first portal and adjacent to the superior edge of the subscapularis tendon. Provisional triangulation with an 18-gauge spinal needle is helpful to determine the appropriate medial to lateral and superior to inferior location (Fig. 4B). After establishing the 3 portals, a complete diagnostic arthroscopyis performed. The quality and laxity of the GHLs and labrum is examined, and the ease of passage of the arthroscope from posteriorly to anteriorly into the inferior pouch (the drive-through sign)is assessed. The location of the labral detachment is identified. Poor-quality labral tissue or the lack of a welldefined anterior band of the IGHL is a relative contraindicationto this procedure. Glenoid and Labrum Preparation

Meticulous preparation of the scapular neck is performed by a series of steps (Fig. 5). The Bankart lesion is extended down to the 6 o'clock position with an electrothermal device, the labrum is elevated using a sharp-tipped rasp, loose tissue is debrided with a motorized shaver, and a motorized burr is used to create a bleeding cancellous bed on the anterior scapular neck 10 to 15mm from the edge of the glenoid. It is helpful to visualize the preparation process with the arthroscope through the anterosuperior portal and instrument through the anteroinferior portal. Drilling the Glenoid and Tensioning the Soft Tissue

Figure 3. The drill and guidewire construct. The drill bit is cannulated to receive the guidewire that is fixed proximally with a set screw so that the tip protrudes 3 to 4 rnrn from the end of the drill.

The cannulated drill is inserted through the with the guidewire locked in place SO that 2 to 4 IIun extends beyond the drill bit tip. The arm is placed into adduction and slight external rotation. A soft-

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Figure 4. Portal placement relative to intra- and extraarticular structures. (A) The patient is seated in the beach chair position. An anterosuperior portal is placed just lateral and superior to the palpable coracoid process so that it pierces the rotator interval capsule and enters intraarticularly at the level of the insertionof the biceps tendon onto the superior labrum. This cannula may be used to enhance inflow if no pump is used, or it may be used for outflow when a pump is used. (8) A second anterior portal is established to receive the 7-mm cannula-trocar assembly inferior to the first portal, adjacent to the superior tendon of the subscapularis, lateral and inferior to the coracoid process.

tissue grasper is placed through the anterosuperior portal to tension the labrum and capsule superiorly, taking great care not to medialize the tissue on the glenoid neck. The detached tissue is then captured with the drill and guidewire and approximated to the prepared anterior scapular neck beginning as low as possible (ie, at or below the 4 o’clock position in the right shoulder) adjacent to the glenoid rim. Typically, the hand holding the drill is angled obliquely from superolateral to inferomedial to avoid inadvertent skiving across the glenoid surface (Fig. 6A). The drill and guidewire construct is advanced 1 marking on the drill, which is equal to 1 length of the Suretac implant (16 mm) (Fig. 68). The set screw located proximally on the drill is loosened and the guidewire is tapped using the guidewire handle to secure it within the bone and free it from the drill (Fig. 7). The drill bit is carefully withdrawn over the wire, which is left within the trocar cannula. An alternative technique involves bony preparation and drilIing before penetrating the soft tissue with the guidewire. This technique may improve fixation when tissue quality tissue is marginal.

Placement of the Implant

The tack is impacted over the guidewire using a cannulated driver to transfix the labrum to the glenoid neck (Fig. 8). The guidewire is removed through the driver. Typically, 2 to 3 tacks are used beginning inferiorly and progressing superiorly along the neck until the entire lesion is secured. The repair is considered complete if the normal anatomy of the IGHL is securely restored and the drive-through sign is eliminated (Fig. 9A). Visualization and probing through the anterosuperior portal is helpful to assess the quality of the anatomic restoration of the IGHL complex and to assess for potentially inadequate soft-tissue purchase (Fig. 9B). POSTOPERATIVE CARE

The maximum protection phase requires that the shoulder be immobilized in a sling and swathe for 3 to 4 weeks except during simple daily exercises. These exercises include isometric muscle contractions, pendulum ex-

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Figure 5. Arthroscopic view through the posterior portal. (1) A small rasp is used through the anterosuperior portal to elevate the labrum and to roughen the anterior scapular neck down to the 6 o’clock position. (2) An arthroscopic burr completes the preparation of the bone to create a bleeding cancellous surface. (3)The labrum is mobile and well defined. (4) The bleeding prepared cancellous surface.

ercises allowing forward elevation up to 90°, and elbow, wrist, and hand movement, as well as grip strengthening. The sling is removed after the maximum protection phase and active-assisted supine forward elevation is added to the exercise program. Active-assisted external rotation is delayed until after the sixth week. At 8 weeks, resistive strengthening of the rotator cuff and scapular stabilizers is instituted, but passive stretching, especially external rotation, is delayed for 12 weeks. At 4 months, nonoverhead athletes are allowed to return to sport. Overhead athletes may return to sport by 6 months following a transitional period of sport-specific exercises provided that motion and strength are restored.

capsulorrhaphy. To date, however, there is insufficient clinical information to recommend these procedures as a routine adjunct to arthroscopic stabilization.62-66Our recommendations at this time include an anatomic stabilization of the Bankart lesion as the first priority, then thermal reduction of the capsular laxity if persistent pathologic capsular deformation persists. When applying techniques such as electrothermal arthroscopic capsulorrhaphy, respect for the initial healing and revascularization phase must be observed. The rehabilitation program needs to be adjusted to include external rotation exercises after 2 to 3 weeks, although an effort toward full external rotation is still not allowed until after 6 weeks and may not be achieved until 12 weeks after surgery.

THERMAL CAPSULORRHAPHY Persistence of pathologic translation after the labral stabilization is generally attributed to deformation of the capsule. Reducing capsular laxity has been simplified with new techniques including electrothermal arthroscopic

RESULTS Several authors report excellent results with cannulated bioabsorbable implants to treat traumatic anterior shoulder instability. Re-

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A

Figure 7. After drilling, the set screw on the drill is loosened and, using the guidewire handle, the wire is tapped to free it from the drill before removal.

B Failure of fixation is most commonly caused by poor tissue, but may also be related to poor technique such as an incomplete seating of the implant (Fig. Premature return to highlevel activities is also associated with failure in several Most series report on relatively pure populations of traumatic anterior instability with some series recommending arthroscopic stabilization in the acute setting for those at very hi h risk for recurrence (ie, contact athletes).69.k

Figure 6. (A) The cannulated drill and guidewire are inserted through the anteroinferior portal as a soft-tissue grasper tensions the labrum and IGHL. The labrum and IGHL are penetrated and shifted superiorly and slightly medially. (B) The drill and guidewire are then advanced into the anterior scapula for a depth of 1 marking (16 mm) on the drill bit.

ported rates of failure range from 0% to 21% (Table1).33"8Higher failure rates are primarily attributable to errors in patient selection and premature return to sport. Under optimal circumstances with refined indications, recurMotion rence rates range from 10% to 16%.37,38 loss is minimal and rarely more than 10" in any p~ane.~~,~~

Figure 8. The cannulated implant is inserted over the guidewire and a cannulated impactor is tapped to set the implant securely against the sofi tissue and prepared bony surface.

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TABLE 1. Arthroscopic Cannulated Bioabsorbable Implant

Mean Follow-up Recurrence Patients ("/.I (mo)

No. of

Study

Cole (1999)% Resch (1997)68 Speer (1996)47 Laurencin (1996)37 Arciero (1995)69 Arciero (1995)70 Resch (1992)71 Warner (1991)% Warner (1991)36

37 53 52 19 19 63 18 26 20

52 35 42 37 19 >24 11 >24 32

16 9 21 10 0 13 6 8 10

jection can be perf~rmed.~' Problems related to soft tissue include penetrating the ligament during impaction of the implant (Fig. 10). Inadequate glenoid preparation or improper soft-tissue tensioning may also lead to early failure. Articular cartilage damage can occur with improper drill placement or technique. Implant placement too far medially along the scapular neck can result in excessive loss of external rotation or compromised labral healing (Fig. 11).Problems related to the implant include implant fracture and hardware failure (Fig. 12). DISCUSSION

The advantages of the Suretac device for use in treating traumatic anterior instability include the simple insertion technique and good results when the repair involves only labrum reattachment. The implant is compatible with magnetic resonance imaging and is radioluFigure 9. (A) Arthroscopic view is through the posterior portal while probing the secured labrum and IGHL (HH, humeral head; G, glenoid). (B) Arthroscopic view is through the anterosuperior portal verifying the position of the labrum and IGHL against the scapular neck with a probe in the anteroinferiorportal. (Lat, lateral; Ant, anterior; HH, humeral head; Post, posterior; IGHL, inferior glenohumeral ligament).

COMPLICATIONS

A unique complication associated with this implant is a nearly 5% incidence of intracapsular synovial reaction. The initial treatment is nonsteroidal medications. If that is unsuccessful, arthroscopic lavage, debridement, and an intraarticular steroid in-

Figure 10. Arthroscopic view through the anterosuperior portal shows implant placement with tearing of the IGHL tissue in a patient who subsequently developed recurrent instability.

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CONCLUSION

Arthroscopic Bankart repair with a cannulated bioabsorbable implant is technically easier than many of the newer arthroscopic suture techniques for treating recurrent traumatic anterior instability. Patient selection is critical to success. The ideal patient is one with unidirectional, traumatic anterior instability with minimal deformity of the glenohumeral capsule. References Figure 11. Medial placement of the upper implant compromises tissue compression in the juxtaarticular area (arrow).

cent on plain radiographs. Disadvantages include the limited ability to address capsular laxity and inadequate fixation of poor-quality capsuloligamentous structures. The ideal patient for an arthroscopic Bankart repair using the Suretac implant will have (1)a discrete Bankart lesion, (2) a robust, welldeveloped IGHL, (3) no significant capsular laxity or intraligamentous injury, and (4)absence of concomitant intraarticular pathology. Significant GHL pathoanatomy, either detachment or deformation, represents a poor prognostic indicator for a successful outcome of arthroscopic Bankart repair using the Suretac device. In these cases, alternative techniques should be used. Our results compare favorably with traditional open techniques in terms of return to full activity and range of motion, and patient satisfaction with strict selection criteria.38

Figure 12. Inadvertent directional change during drilling can lead to bending of the guidewire and implant failure.

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