Bankart Repairs in Elite Rugby Players
My name is Gavin Jennings. I’m a specialist shoulder surgeon. The subject of this talk is Bankart repairs in the high level rugby player.
As far back as 1923 Bankart recognised the importance of his eponymous lesion in shoulder instability. He described this as the essential anatomical defect in the unstable shoulder and that the only rational course of action was to repair this lesion in patients with instability. This is very much the current approach used for the elite contact sportsperson.
In rugby, the most common mechanisms leading to a subluxation or dislocation are forced abduction and external rotation along with direct blows to the shoulder. Dislocations most commonly occur in the tackle situation.
There are potentially some differences in injury patterns in elite rugby players compared to those seen in the recreational player. There may be fewer frank complete dislocations in the elite group (perhaps due to the well developed musculature), there may be a higher incidence of cartilage injuries and they may be more likely to have bone loss (probably due to the higher forces involved)
I will discuss the details of the arthroscopic Bankart repair in this case using a knotless suture anchor system. Potential advantages of this system are that it is of course knotless thereby removing the risks of intra-articular suture stacks, the tension and amount of capsular shift can be adjusted and the technique can be used employing a single anterior portal, reducing the damage to the mid-substance of the capsule.
So how do we ensure the right outcomes from surgery in this patient group whose livelihood may depend on achieving stability in the shoulder.
The first thing to consider is whether stabilisation surgery is appropriate. The elite athlete will often have had an MRA revealing a Bankart lesion prior to consultation. The player should be assessed for instability, both anterior and posterior, and a comparison made with the uninjured shoulder. In the elite player particularly, it may be difficult to detect instability in clinic and it may only be after muscle relaxation following induction of anaesthesia that the instability can be demonstrated. For an arthroscopic Bankart repair alone to be appropriate there should not be significant bone loss either on the glenoid or humeral sides. Any associated pathology should also be considered.
The timing of surgery also needs to be considered. and is not always performed asap. For example if a player had not sustained a frank dislocation, had rehabilitated rapidly following injury and was able to continue playing with only one or two more vital games to play it would clearly make sense to defer surgery until the close of the season.
It is important to have the right set up for surgery and this is essentially down to the surgeon’s personal preference and experience as there is no evidence to suggest that outcomes differ between beach chair and lateral.
The procedure should commence with an EUA then a diagnostic arthroscopy. This should also include a confirmation of the presence of the Bankart, assessment for a positive drive through, assessment for glenoid bone loss or Hill-Sachs lesion and the exclusion of a HAGL lesion.
Once the appropriate pathology has been confirmed, a standard rotator interval portal is made. If there is additional superior labral pathology an anterosuperior portal is made in addition as seen here.
The next step is to adequately mobilise the labrum,
and then to debride the glenoid neck to encourage healing of the labrum once reduced and held. Achieving a bleeding bone surface is probably desirable.
Next a suture is passed. If using a single portal technique adequate monofilament shuttle suture should be inserted to allow the passing instrument to be withdrawn leaving the portal clear without pulling the stitch out of the labrum. If there is a second portal, the stitch can be grasped straight off and withdrawn before the passing instrument is removed.
For a single portal technique, the instrument is withdrawn leaving the suture through the labrum. This is then grasped on the joint side, withdrawn and tied to the definitive suture.
This is then shuttled through the labrum.
If a second portal has been used, the suture will then need to be retrieved so that both ends emerge through the anterior portal.
If there is any difficulty inserting the suture low enough in the labrum in the first instance, a second suture can be inserted more inferiorly using the first as a traction suture to pull the labrum upwards.
The second definitive suture is then shuttled through the labrum.
The appropriate amount of capsular shift can be determined by pulling the suture to the planned site of fixation and then testing external rotation, ensuring that whichever position is selected will not result in over tightening the shoulder
A knotless anchor is then used to fix the inferior most suture into position.
The anchor is first loaded onto the suture ends and a haemostat is then applied to prevent the anchor from slipping off the sutures.
A hole is then drilled just onto the face of the glenoid taking into account the need for any capsular shift. Care must be taken to ensure that the sutures do not become entangled in the spinning drill.
The pre-prepared anchor is then inserted into the drill hole and tapped in with a mallet until the anchor itself is just buried.
The green retention suture is then removed and the anchor inserted until the laser mark is buried. A good bumper of soft tissue results. The suture limbs are then further tightened and then inserted into the cleats on the anchor handle. The central pin is then screwed in to fix the sutures within the anchor. The sutures are removed from the cleats and the inserter is then removed.
Further anchors are inserted progressively more superiorly. On average, for an isolated Bankart repair, three anchors are used, ensuring that the drill holes are adequately spaced to avoid the risk of a glenoid rim fracture on return to contact activities.
Security of the fixation is confirmed.
The extent of the external rotation range before the repair comes under tension is then determined to help guide the safe range during early rehabilitation. The abolition of any drive through sign and of instability are then confirmed.
The principles of post-operative rehabilitation are the same as for any Bankart repair i.e. allow adequate time for healing whilst progressing ROM, restoring proprioreception and muscle control and strength.
The time frame for achieving these aims is usually shorter in the elite player, however.
Such players would be expected to return to match play within three months of surgery and can be within as little as eight weeks.
Thank you for listening to this talk.
Please do not hesitate to contact me or consult the website for any further information.