triantafyllou

1. “Arthroscopic suture-anchor Bankart repair
for recurrent anterior shoulder dislocations
in young football players”
Triantafyllou Ch.
Kapsampelis Al.
From Euroclinic Hospital in Athens

2. 75% of all shoulder dislocations occur in the
position of external rotation and abduction
during athletic activities
(Baker CL and colleagues Am J Sports Med 1990)
When an anterior shoulder dislocation
happens for first time:
• 100% re-dislocation rate in patients younger than 10 years
• 94% between the ages 10 and 20 years, and…
• 79% between the ages of 20 and 30 years
(Bowe and colleagues J Bone Joint Surg Am 1984)
Basic Facts

3. Bankart lesion occurs in 94% of first time
acute traumatic dislocations in young
patients
(Taylor DC, Arciero RA: Am J Sports Med 1997)
Bony Bankart lesions have been reported
in 22% of primary dislocations
(Rowe CR, Patel D, Southmayd WW J Bone Joint Surg Am
1978)
Basic Facts

4. Hill-Sacks lesions have been reported in 32% to 51%
of initial anterior dislocations and concurrent
glenoid and humeral head bone defects exist
in nearly 100% of cases of repetitive dislocations
(Calandra JJ, Baker CL, Uribe J: Arthroscopy 1989)
HAGL lesions (Humeral Avulsion of the
Glenohumeral Ligaments) have been reported
in 7.5% to 9.3% (generally in an older patient
population)
(Bokor DJ, Conboy VB, Olson C J Bone Joint Surg Br 1999)
(Wolf EM, Cheng JC, Dickson K: Arthroscopy 1995)
Basic Facts

5. The labrum increases the depth of the
glenoid up to 50%
(Bigliani LU, Kelkar R, Flatow EL et al: Clinic Orthop Relat Res
1990)
By reducing the labral height by 80% the
resultant stability of the glenohumeral joint
decreases by 60%
(Lazarus MD, Sidles JA, Harryman DT II, Matsen FAIII J Bone
Joint Surg Am 1996)
Basic Facts

6. 28 football players (10 goalkeepers)
Mean age 24.64 yrs (range 19-33 yrs)
From 2005 to 2010
1-3 unilateral anterior post-traumatic shoulder
dislocations
Mean follow-up period 50 months
(range 27-88 months)
Materials

7. None of the patients had a Hill-Sachs lesion more
than 20% of the humeral head
None of the patients had a bony Bankart lesion
more than 20% of the glenoid width (The width of
the glenoid is about 25mm)
None of them had a traumatic humeral avulsion of
the glenohumeral ligaments (HAGL lesion)
None of them had a serious rupture of the rotator
cuff
Materials

8. NORMAL ANTERIOR DISLOCATION

9. NORMAL BONY BANKART DEFECT

10. MRI
Normal
MRI
Bankart lesion

11. MRI ARTHROGRAPHY
Normal
MRI ARTHROGRAPHY
Bankart lesion

12. General
anaesthesia
Interscalene
nerve block

13. Beach chair position

14. Posterior
viewing portal
Anterior portals

16. Arm on a sling 0-4 wks postop
12 wks, a single upper limb therapist
Two 45min sessions per week
Home exercises according to written &
oral instructions
Gradually advancing ROM exercises
Shoulder muscles’ strengthening with free
weights and elastic bands
Rehabilitation Program

17. Exercises for activation of the glenohumeral
head’s and scapula’s stabilizing muscles
Proprioception training with closed kinetic
chain exercises
Neuromuscular co-ordination training of
scapulohumeral rhythm
Glenohumeral joint’s capsule stretching
exercises
Special Features of the Rehabilitation Program

18. 0-4 wks
4-6 wks
8-12 wks
6-8 wks
Arm on sling, pendulum, shoulder flexion up to 90o,
scapula’s stabilizing muscles’ activation, biceps & triceps
strengthening, deltoid isometric
Shoulder abduction to 90o and external rotation to 0o,
glenohumeral’s stabilizing muscles’ activation (elastic band),
deltoid isotonic strengthening (free weights and elastic band)
Full ROM, isotonic strengthening of rotator cuff muscles
(free weights and elastic band) and scapula’s stabilizers
(free weights and rowing machine), closed kinetic chain
exercises for proprioception
Glenohumeral joint’s capsule stretching, continue of
stabilizing exercises and all shoulder and scapula muscles’
strengthening
Rehabilitation Program

19. Strengthening and stretching at the gym
Gradual return to their team’s training
sessions under close supervision
Check every 2 wks to decide the appropriate
time to return to full sport’s activity
After the 12 wks Postop

20. At the end of the rehabilitation process all
patients were assessed using the Constant
Shoulder Score
At the time of the final follow-up were
contacted by phone and asked to fill in a
self evaluating quality of life questionnaire
for shoulder instability (the Western Ontario
Shoulder Instability Index) send to them
by mail
Evaluation of Patients’ Progress

21. The official score of the European Society of
Shoulder and Elbow Surgery
Combines physical examination tests with subjective
evaluation by the patients
Subjective assessment: 1 item for pain (15 points)
and 4 items for activities of daily living (20 points)
Objective assessment: ROM (forward elevation 10
points, abduction 10 points, ext. rot. 10 points,
int. rot. 10 points), and power (25 points)
Best possible score: 100 points
Constant Shoulder Score

22. Evaluates the patients’ perception of treatment’s success and
feeling of shoulder’s stability
Contains 21 questions in 4 domains: physical symptoms,
sports, recreation and work
The best possible score is 0 (=no decrease in shoulder related
quality of life)
The worst possible score is 2100 (=extreme decrease in
shoulder related quality of life)
The most recommended questionnaire for shoulder instability
evaluation since it has proved highly valid, reliable and
sensitive to change
(Kirkley et al. 1998, Kirkley et al. 2003, Plancher & Lipnick 2009,
Salomonsson et al. 2009)
Western Ontario Shoulder Instability Index (WOSI)

23. Patients Age( years) Return (months) Constant Score WOSI Score
Follow-up
(months)
1 22 8 96 45 88
2 23 7 96 52 83
3 25 6 100 49 78
4 24 6 100 57 71
5 21 8 96 48 69
6 23 8 96 247 60
7 26 8 96 66 59
8 27 7 96 58 57
9 28 6 100 49 56
10 21 8 96 54 54
11 28 6 100 62 52
12 20 8 96 308 50
13 31 6 100 47 49
14 25 6 100 50 49
15 20 8 96 304 46
16 21 7 96 57 46
17 30 7 96 61 43
18 27 8 96 64 42
19 20 8 96 44 41
20 31 6 100 54 40
21 22 7 96 62 39
22 26 6 100 46 38
23 28 7 100 59 37
24 20 8 96 340 33
25 29 6 100 65 31
26 19 8 96 406 30
27 33 7 96 63 28
28 20 8 96 110 27
Patients’ data

24. The mean Constant score was 97.42 ± 1.95
with all patients scoring excellent
24 patients (85.72%) returned to pre-op
sport’s level and 4 (14.28%) returned to a
lower level after a mean of 7.1 ± 0.87 months
1 patient (a goalkeeper) suffered a traumatic
re-dislocation (rate 3.57%) and underwent
revision arthroscopic operation
Results (at the end of the rehabilitation process)

25. 23 patients had excellent, and
5 had good WOSI scores
Mean WOSI score 104.00 ± 101.50
Results (at the final follow-up)

26. The arthroscopic Bankart repair with the
correct use of suture anchor and when
the appropriate rehabilitation program is
followed it is a reliable treatment with
good clinical outcomes excellent post-
operative shoulder motion and low
recurrent rates even for high level
football players
Conclusion

27. Triantafyllou Ch.
Kapsampelis Al.
From Euroclinic Hospital in Athens