Bankhart Repair – Arthroscopic Stabilization of the Shoulder

Bankhart repair, also known as arthroscopic labrum repair of the shoulder, is performed to fix a detached labrum. The labrum is a circumferential structure that is surrounds the glenoid, which is the boney socket of the shoulder. There are also ligaments that surround the shoulder that attach to the labrum. Together the labrum and the attached ligaments act as a stabilizer for the joint.

A Bankhart tear occurs when the labrum is torn away from the bone. These tears are often a result of a shoulder dislocation which also tears the anterior inferior glenohumeral ligament. Because the ligaments and labrum are no longer attached to the bone, the shoulder becomes unstable and requires appropriate treatment.

Acute Bankart tears are more common in young individuals, usually under the age of 35. Initially, conservative treatment may be implemented, but if repeat shoulder dislocations occur, surgical repair of the labrum and ligaments is recommended. When surgery is indicated, arthroscopic stabilization of the shoulder or a Bankart repair is performed. 

How is the Bankart Repair Performed?

The Bankhart repair is performed by making a few small incisions in the front and back of the shoulder. A video camera (arthroscope) is inserted to view the inside of the shoulder joint. Small instruments are then inserted to perform the repair. 

The first step of the Bankhart repair is to prepare the area around the detached labrum. Any loose particles are removed and rough edges are made smooth. The orthopedic surgeon then drills a small hole in the bone by the detached labrum. An anchor and suture are then placed in the hole, and the suture from the anchor are sewn into the labrum and pulled tightly to reattach it to the glenoid. The steps are repeated for each anchor, and the amount of anchors used depends on the size of the labrum and ligament tear. The small incisions are then sutured closed. 

After the procedure, the patient is asked to remain in a sling for about 4 weeks to allow the labrum to heal to the bone. Physical therapy is then typically prescribed 3x a week for 12 to 16 weeks. Patients can normally return to desk work after 2-4 weeks and physical labor and sports within 4 months. 

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If you suspect you have a labral tear it is important to see an orthopedic surgeon. To schedule an appointment with board certified orthopedic surgeon, John Vitolo, MD, call 973-300-1553.

Prevention of Shoulder Impingement & Bursitis

When the shoulder is injured, inflammation occurs causing pain and weakness in the shoulder. This can greatly impact a person’s quality of life. Shoulder Impingement, Tendonitis and Bursitis are two common conditions that can cause pain and discomfort. 

In order to understand shoulder pain and injury, it is important to learn about the anatomy of this joint. The shoulder is a ball-and-socket joint made up of three bones: the humerus (upper arm bone), scapula (shoulder blade), and clavicle (collarbone). The head of the humerus fits into the glenoid (a rounded socket in the scapula). These bones are held in place by muscles, tendons and ligaments. The ligaments hold the bones together and create stability, while the tendons connect the muscles to the bones and the muscles make movement possible.

Three common shoulder conditions are: shoulder impingement, tendonitis and bursitis. Shoulder impingement occurs when the space between the acromion and rotator cuff narrows and the acromion rubs on the tendon or bursa.  This results in pain and irritation. Tendonitis occurs when the rotator cuff tendons and/or the bursa become irritated and inflamed and bursitis occurs when the bursa becomes inflamed and swollen with fluid. It is common for these conditions to occur in conjunction with one another since they are adjacent structures.

Symptoms of shoulder bursitis, tendonitis and impingement include:  

• Pain while performing an activity and at rest
• Pain that radiates from the front of the shoulder to the side of the arm
• Pain with throwing
• Pain with overhead motion 
• Sudden pain when lifting/reaching
•  

Shoulder bursitis, tendonitis and impingement are often caused by overuse and improper lifting techniques. To help prevent these common shoulder injuries, follow these helpful tips:

• Exercise regularly and strengthen the muscles of the shoulder joint
• Focus on upper body strength and flexibility
• When lifting and reaching overhead, pay attention to the position and form of your back
• When lifting, keep back as straight as possible, bend and lift with your legs
• When reaching to place or retrieve heavy objects, use a stable platform or stool
• Know when to say when – when you are tired and fatigued; take a break!

Depending on the severity of the injury, shoulder impingement or bursitis can be treated non-surgically through rest, cortisone injections and physical therapy. In some cases surgery may be required.  If surgery is indicated, minimally invasive, arthroscopic surgery to is the best method to repair the injury, followed by a rehabilitation program to get you back to full activity as quickly as possible. For more information or to schedule and appointment with John Vitolo, MD, please call 973-300-1553 or visit advocareorthosportsmed.com

Looking At the Whole Picture

Medical tests have evolved dramatically over the past 50 years. MRIs are revealing details of the anatomy that we could not see historically. The advances are incredible and valuable, but as physicians, we must remember the importance of looking at the full picture.

In my experience, each tool we use fits a piece of a puzzle that reveals the most appropriate treatment protocol. We cannot and should not depend solely on imaging to determine if surgery is needed. The imaging tools today are advanced and may show an injury that is not necessarily the root of the pain. In order to determine the most appropriate treatment we must also rely on the physical exam and medical history of the patient.

Exams

Traditional physical exams are vital to identifying the appropriate course of action when treating patients. For example, a patient complaining of shoulder pain may have an MRI showing multiple injuries. However, it is possible that one injury was pre-existing and not the root of the pain. By utilizing physical exams, such as the Hawkins-Kennedy Impingement Test or the Neer’s Test, we can identify the injury causing pain and then use the MRI to gather more information. 

History

It is vital to talk to patients and gather information about their personal medical history. By understanding the type of work they do and the lifestyle they lead, we can determine the treatments that will be most effective. For example, certain surgical procedures may be more appropriate for athletes, while a more conservative approach may be the better option for someone who works a desk job. 

Imaging

Imaging provides physicians with the ability to see inside the body and identify the scope of the injury or condition. X-rays give us a way to see bones and diagnose fractures and arthritis, while MRIs allow us to see the soft tissues. CT scans provide images of internal organs, bones, soft tissue and blood vessels and are able to provide greater detail than traditional x-rays, particularly of soft tissues and blood vessels.

In this technologically advanced world we live in, it is important to remember that all the diagnostic tools tie together to create the most appropriate treatment plan for each patient. If we as physicians solely relied on one piece (i.e. imaging) we may be doing a disservice to the patient and miss a detail that could be vital to that person’s recovery. In an upcoming series, we will review tests that are used during orthopedic physical exams and describe what each test is used to diagnose.

Injury Prevention: Little League Pitch Counts and Rest

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We have discussed pitch counts and injury prevention for our young athletes in the past, but with baseball season upon us, it is important to remind parents and athletes of the guidelines. Young athletes feel invincible and feel injury "won't happen to them". As a physician with over 20 years of experience in sports medicine, I can assure you that injuries can and do happen. Luckily, some simple precautions can help minimize injury risk.

It is important to mention that while the old adage “practice makes perfect” is true, our youth need guidance in order to prevent injury. Overuse injuries in school aged athletes are on the rise. The incidence of shoulder and elbow injuries among youth baseball and softball players is five times greater than it was in the year 2000.[i]

Many of these baseball injuries are preventable. In recent years, Little League Baseball has released guidelines and enforced regulations to help prevent injury in young athletes (see charts below). The league has put limits on pitch counts during games and also enforced required rest periods. All the guidelines are based on the age of the athlete.

While the guidelines from Little League Baseball are important, there are additional steps that can be taken at practices and off the field.

Here are some tips:
1. Always warm up – stretch, jog and begin with some easy, gradual throwing
2. Try different positions – different positions require the use of various muscle groups
3. REST – don’t play year round and allow rest between games
4. Focus on your form, accuracy and control
5. If you have shoulder or elbow pain, do not pitch
6. Talk to your parents and coaches about any pain – do not play through the pain!

Getting kids involved in sports at an early age is a great idea, but it is important to remember an injury can end their baseball career too soon. By following the suggestions outlined here, injury can be avoided and a lifelong love of baseball and activity can be built!

Case Study: Chronic Knee Dislocations Due to Work Injury

A 31 year old male patient came into the office complaining of continuous knee pain. He also complained that his kneecap would “give out”. During the examination, we determined the problems began back in 2008 following a work injury. The patient explained that during the incident, he had twisted his knee at work, which had caused his knee to dislocate.

At the time, the patient had been treated with physical therapy and a brace. He was able to return to work following the injury but continued to suffer with the symptoms described above for years. Upon examination, it was determined that he was suffering from chronic patella instability and multiple dislocations.

As part of the examination, we noted the following:

•           Knee swelling

•           Increased patella laxity

•           Positive patellar apprehension sign

•           Increased Q angle

Before determining the exact treatment protocol, the increased Q angle indicated the need to perform a CT scan to measure the distance between the tibial tubercle and the trochlear groove. This is referred to as the T-T distance. A T-T distance greater than 2.0 cm requires the anteromedial transfer of the tibial tubercle and will decrease the T-T distance. This will encourage improved stability of patella.

It was determined that the best treatment approach was to combine two surgical procedures at the same time. The first procedure is referred to as MPFL reconstruction. The medial patellofemoral ligament or MPFL is a thin band of tissue that attaches the kneecap to the inner part of the knee. When the kneecap dislocates, it often tears the MPLF on the inside of the knee, which is important for stability in the knee. During the procedure, the MPFL is reconstructed and re-attached in the most anatomically correct position. To do this, we used a hamstring allograft and replaced the torn MPFL.

The second procedure is referred to as anterio-medialization of the tibal tubercle. The operation focuses on recentering the patella and reduces patellofemoral contact pressure. This improves the Q angle and reduces lateral vector force on the reconstructed MPFL.

The surgery proved to be a success. Following surgery, the patient was in a hinged brace and utilized crutches for 4 weeks. He then completed 12 weeks of physical therapy that was focused on edema control, range of motion and strength training. He was able to return to his job as a laborer 3 months post-op. He is currently doing extremely well and no longer suffers from patellar instability. He currently works 50-60+ hours per week without difficulty. 

Lateral Patellar Instability and the Medial Patellofemoral Ligament (MPFL)

Lateral patellar instability occurs when the kneecap dislocates out of place. The kneecap or patella is a small bone in the front of the knee. It glides along the femoral groove (a groove in the femur bone) as the knee bends and straightens. If the patella comes out of the groove completely, it is referred to as patellar dislocation. If the patella comes out of the groove partially, it is referred to as patellar subluxation.

Symptoms of dislocations of the kneecap are as follows:

-          Pain at the knee joint
-          Swelling
-          Obvious displacement of the kneecap (kneecap can often briefly dislocate and return, but pain and swelling will still be present)

When the kneecap dislocates, it often tears the medial patellofemoral ligament on the inside of the knee. The MPFL is a thin band of tissue that attaches the kneecap to the inner part of the knee. The medial patellofemoral ligament or MPFL is important for stability in the knee.

There are surgical and non-surgical treatments for patellar instability. Rest, ice and bracing have been known to heal the injury and prevent recurrent dislocations. However, surgical intervention is sometimes needed to correct recurrent dislocations.

If the MPFL is torn, the patient can potentially benefit from a surgical procedure known as MPFL reconstruction. Reconstruction of the MPFL is a surgical procedure that restores patellofemoral stability. The most successful and widely accepted approach to this procedure is to use an approach that restores the MPFL to its anatomically correct position. This procedure, along with other options, such as tibial tubercle osteotomy, and/or a trochleoplasty can be used to correct the problem. The exact treatment protocol varies by individual.

 

Prominent Orthopedic Surgeon to Open Office in Chester, NJ

Advocare Orthopedic and Sports Medicine Center, the office of NJ Top Doc orthopedic surgeon, John Vitolo, MD announced the opening of a satellite office in Chester, NJ on January 27^th 2015. The office will be located at 530 East Main Street in Chester, Suite 4A, with Advocare Aygen Pediatrics and Adult Care. This office location is being established to better suit the needs of patients from Morris County.

The new office is Advocare Orthopedic and Sports Medicine Center’s second location. “Opening the office in Chester is an important step toward expanding our practice into Morris County,” said Vitolo, “When we were presented with the opportunity to open an office in Chester, we looked at the area and noticed a need for orthopedic care. We are very excited to have this opportunity to offer quality orthopedic care in the area.”

The new office will focus on the treatment of orthopedic injuries and conditions of the shoulder and knee. Dr. Vitolo has over 20 years of experience treating sports and workplace injuries. Dr. Vitolo is committed to providing the highest quality, individualized care to his patients.

John Vitolo, M.D. is board certified in Orthopedic Surgery and holds a Subspecialty Certification in Sports Medicine.  Dr. Vitolo specializes in arthroscopic surgery of the shoulder and knee and was a former team physician for the Boston Red Sox.  He received his undergraduate degree from Brown University, then attended Columbia University and the University of Medicine and Dentistry of New Jersey.  Dr. Vitolo’s main office is located at 540 Lafayette Rd in Sparta, NJ.  Dr. Vitolo is currently accepting new patients and is also available for IME’s and second opinions. Please call (973) 300-1553 or visit advocareorthosportsmed.com for more information.