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

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

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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

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SLIDE 1

The Open Bankart is Best for the Collision Athlete

Theodore F. Schlegel, MD

UC Health / Steadman Hawkins Clinic – Denver

Orthopaedic Summit Las Vegas, Nevada December 8th, 2017

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SLIDE 2

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

Disclosures

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The Pendulum Has Swung Too Far

  • 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…

Arthroscopy, April 2014

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SLIDE 4

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

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SLIDE 5

Open Bankart vs. Arthroscopic meta-analysis

Open Bankart

  • less recurrence
  • less re-operation
  • > return to work
  • > return to sport

Lenters, et al, JBJS 2007

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SLIDE 6

Open Bankart vs. Arthroscopic Systematic Review

Revision surgery

  • Arthroscopic: 57%
  • Open: 19%

Harris, et al, Arthroscopy 2013

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SLIDE 7
  • 23% scope RR vs. 11% open

JBJS 2014

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But this is for all comers: What about for populations it matters in?

  • 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!

Cho NS et al, Arthroscopy 2006

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SLIDE 9

Is Arthroscopy = to Open in the Contact Athlete

  • 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%

AJSM 2006

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SLIDE 10

Arthroscopic Deal Breaker: Bone Loss

  • 194 consecutive patients with

Bankart Repair

  • 6.5% recurrence without bone loss
  • 67% recurrence with bone loss
  • Contact athletes with bone loss

89%

Arthroscopy 2000

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SLIDE 11
  • Quantified risk for

scope stabilization

  • Bone loss contributed

to 75% failure in scores >6

Balg and Boileau, JBJS Br. 2007

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What is the Appropriate ISIS Score to Use?

AJSM 2015 OTSR 2010

  • 70% failure for ISIS >3
  • 4% Failure if ISIS 3 or less
  • If use ISIS 3 or less - 41% of

population needs OPEN High School Contact Athlete: 3

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SLIDE 13

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)

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The Future:

  • “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

Tokish, et al, AJSM 2014

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SLIDE 15

There are real consequences to failure

  • f a Bankart Procedure…
  • “It might do fine…”
  • “even if it does fail,”
  • “you can always

revise it, and get a do

  • ver…”
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SLIDE 16

Results of scope revision stabilization

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!

  • There are real consequences of a failed

Arthroscopic Bankart procedure

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SLIDE 17

The Gold-Standard – Open Bankart

  • 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

JBJS, 1978

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SLIDE 18

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!
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SLIDE 19