Arthroscopic Bankart Repair Versus Open Latarjet for First-Time Dislocators in Athletes

BACKGROUND

In athletes with a first-time shoulder dislocation, arthroscopic Bankart repair (ABR) and the open Latarjet procedure (OL) are the most commonly utilized surgical procedures to restore stability and allow them to return to play (RTP).

PURPOSE

To compare the outcomes of ABR and OL in athletes with a first-time shoulder dislocation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of patients with first-time shoulder dislocation who underwent primary ABR and OL and had a minimum 24-month follow-up. Indications for OL over ABR in this population were those considered at high risk for recurrence, including patients with glenohumeral bone loss. Patients who underwent ABR were pair-matched in a 2:1 ratio with patients who underwent OL by age, sex, sport, and level of preoperative play. The rate, level, and timing of RTP, as well as the Shoulder Instability-Return to Sport after Injury (SIRSI) score were evaluated. Additionally, we compared recurrence, visual analog scale pain score, Subjective Shoulder Value, Rowe score, satisfaction, and whether patients would undergo the surgery again.

RESULTS

Overall, 80 athletes who underwent ABR and 40 who underwent OL were included, with a mean follow-up of 50.3 months. There was no significant difference between ABR and OL in rate of RTP, return to preinjury level, time to return, or recurrent dislocation rate. There were also no differences between ABR and OL in patient-reported outcome scores or patient satisfaction. When collision athletes were compared between ABR and OL, there were no differences in RTP, SIRSI score, or redislocation rate.

CONCLUSION

ABR and OL resulted in excellent clinical outcomes, with high rates of RTP and low recurrence rates. Additionally, there were no differences between the procedures in athletes participating in collision sports.

Arthroscopic Bankart repair with all-suture anchors does not cause important glenoid bone osteolysis: a volumetric CT study of 143 anchors

PURPOSE

To evaluate with computed tomography (CT) the incidence of anchor-related osteolysis after implantation of two types of all-suture anchors for the management of labral lesions in shoulder instability.

METHODS

Single-cohort, observational study with 12-month follow-up. Thirty-three participants (27 males/6 females; age 38.3 years [SD 11.3]) with anterior labral lesions in which 143 all-suture anchors (71 Iconix 1.4 mm and 72 Suturefix 1.7 mm) were implanted were evaluated with a CT performed a mean of 15.4 [3.85] months after surgery. The volume of the bone defects was measured in the CT. Every anchor was classified into one of four groups: (1) no bone defect. (2) Partial bone defect (defects smaller than the drill used for anchor placement). (3) Tunnel enlargement (defects larger than the drill volume but smaller than twice that volume). (4) Cystic lesion (defects larger than twice the drill volume).

RESULTS

No bone defect was identified in 16 anchors (11.2%, [95% CI 6.5-17.5%]). A partial bone defect was found in 84 anchors (58.7% [50.2-66.9%]). Tunnel enlargement was found in 43 anchors (30.11% [22.6-37.6%]). No anchor caused cystic lesions (0% [0-2.5%]). The defect volume was a mean of 27.8 mm³ (SD 18.4 mm³, minimum 0 mm³, maximum 94 mm³). Neither the position in the glenoid nor the type of implant used had a significant effect in the type or size of the defects.

CONCLUSION

When using all-suture anchors in the glenoid during instability surgery, relevant bone osteolytic defects are rare at 1-year follow-up. Most anchor insertion tunnels will fill completely (11%) or partially (59%) with bone. Tunnel enlargement will develop in 30% of anchors. No cystic defects larger than 0.125 cm³ were observed. There is a low risk that all-suture anchors cause significant osteolytic bone defects in the glenoid. These implants can be used safely. Level of evidence IV.

Comparable clinical outcomes using knotless and knot-tying anchors for arthroscopic capsulolabral repair in recurrent anterior glenohumeral instability at mean 5-year follow-up

PURPOSE

To compare rates of recurrent instability, revision surgery and functional outcomes following arthroscopic anterior capsulolabral repair for recurrent anterior instability using knot-tying versus knotless suture anchor techniques.

METHODS

 Patients who had undergone arthroscopic anterior labrum and capsular repair for recurrent anterior glenohumeral instability using knotless anchors were identified. Those with minimum 2-year follow-up were matched (1:2) to knot-tying anchor repair patients. Rates of failure and recurrent instability were compared, as well as Visual Analog Scale (VAS), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), University of California Los Angeles (UCLA) and Rowe scores.

RESULTS

One hundred and two patients (89 males, 13 females) with a mean age of 24.3 ± 9.6 were included. Repair was performed with knotless anchors in 34 and knot-tying anchors in 68 shoulders. At mean follow-up of 4.8 ± 2.5 years, re-dislocation rates between groups were not significantly different (knotless anchor: 9% versus knot-tying group: 15%, n.s.), but the knot-tying group showed a higher re-subluxation rate (p = 0.039). 12 (18%) revisions were performed in the knot-tying group at a mean 2.9 years after surgery and 1 (3%) revision in the knotless anchors group at 1.4 years (n.s.). There was no difference in mean VAS with use (1.3 ± 1.9 versus 0.8 ± 1.5, n.s.), SANE scores (91.8 ± 12.7 versus 92.0 ± 11.0, n.s.), QuickDASH scores (4.1 ± 5.5 versus 3.0 ± 6.5, n.s.), UCLA Shoulder Score (32.5 ± 3.6 versus 33.2 ± 3.1, n.s.), or Rowe scores (90.5 ± 18.5 versus 92.2 ± 16.6, n.s.) between knotless and knot-tying groups, respectively. VAS at rest was higher in the knotless group (0.7 ± 1.5 vs 0.1 ± 0.4, p = 0.021).

CONCLUSIONS

Knotless anchors demonstrated similar rates of re-dislocation and revision surgery, and lower rates of recurrent subluxation, compared to knot-tying anchors. Patients achieved good-to-excellent functional outcomes. This supports the efficacy of knotless anchors as an alternative to knot-tying anchors for arthroscopic anterior labral repair of recurrent anterior shoulder dislocation.

LEVEL OF EVIDENCE

III.

Criteria-based return-to-sport testing is associated with lower recurrence rates following arthroscopic Bankart repair

HYPOTHESIS AND BACKGROUND

This study aimed to analyze the impact of a criteria-based return-to-sport (CBRTS) testing protocol on recurrent instability following arthroscopic Bankart repair. We hypothesized that patients who underwent an objective CBRTS testing protocol to guide their clearance to return to sports would have less recurrent instability than those who did not undergo testing.

METHODS

Thirty-six consecutive patients who underwent arthroscopic Bankart repair from 2016 to 2018, had a minimum of 1 year of follow-up, and completed functional and strength testing to evaluate readiness to return to sports were included in this retrospective case-control study. Patients with critical glenoid bone loss > 13.5%, multidirectional instability, and off-track Hill-Sachs lesions necessitating a remplissage or bone augmentation procedure were excluded from the study. Recurrence was defined as dislocation or subluxation symptoms requiring revision surgery. Statistical analysis included analysis of variance and the independent t test.

RESULTS

There was no difference between the study and control groups regarding age (P = .15), sex (P = .11), hand dominance (P = .56), or participation in contact sports (P = .78). Patients who underwent the CBRTS testing protocol had a reduced rate of recurrent shoulder instability (5% vs. 22%; odds ratio, 4.85; P < .001). There was no difference in the time from surgery to recurrence between the groups (12 months vs. 13.6 months, P = .43).

CONCLUSION

Athletes who underwent an objective CBRTS testing protocol to guide their clearance to return to sports had a lower rate of recurrent instability following arthroscopic Bankart repair than those cleared to return based on the time from surgery. Athletes who did not undergo CBRTS testing after arthroscopic shoulder stabilization had a 4.85 times increased likelihood of recurrent instability development after return to sports.

Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long-term results

INTRODUCTION

Arthroscopic stabilisation is a well-recognised surgical technique with a variable rate of failure reported between 0-35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate.

MATERIAL AND METHODS

41 patients that underwent arthroscopic shoulder stabilisation for glenohumeral instability between 2001-2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognised in order to assess possible risk factors.

RESULTS

The overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent/good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery.

CONCLUSION

The arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favourable outcome, with a redislocation rate of 9% and low complication rate.

Three-Dimensional Quantification of Glenoid Bone Loss in Anterior Shoulder Instability: The Anatomic Concave Surface Area Method

Background

Recurrent shoulder instability may be associated with glenoid erosion and bone loss. Accurate quantification of bone loss significantly influences the contemplation of surgical procedure. In addition, assessment of bone loss is crucial for surgical planning and accurate graft placement during surgery.

Purpose

To quantify the concave surface area of glenoid bone loss by using 3-dimensional (3D) segmented models of the scapula and to compare this method with the best-fit circle and glenoid height/width methods, which use the glenoid rim for bone loss estimations.

Study Design

Cohort study (diagnosis); Level of evidence, 2.

Methods

A total of 36 consecutive preoperative bilateral computed tomography scans of patients eligible for a primary Latarjet procedure were selected from our institutional surgical database (mean patient age, 29 ± 9 years; 31 men and 5 women). The 3D models of both scapulae were generated using medical segmentation software and were used to map the anatomic concave surface area (ACSA) of the inferior glenoid using the diameter of the best-fit circle of the healthy glenoid. Bone loss was calculated as a ratio of the difference between surface areas of both glenoids (healthy and pathological) against the anatomic circular surface area of the healthy glenoid (the ACSA method). These results were compared with bone loss calculations using the best-fit circle and glenoid height/width methods. Inter- and intraobserver reliability were also calculated.

Results

The mean (± SD) bone loss calculated using the ACSA, the best-fit circle, and glenoid height/width methods was 9.4% ± 6.7%, 14.3% ± 6.8%, and 17.6% ± 7.3%, respectively. The ACSA method showed excellent interobserver reliability, with an intraclass correlation coefficient (ICC) of 0.95 versus those for the best-fit circle (ICC, 0.71) and glenoid height/width (ICC, 0.79) methods.

Conclusion

Quantification of instability-related glenoid bone loss is reliable using the 3D ACSA method.

Bankart Repair Versus Latarjet Procedure for Recurrent Anterior Shoulder Instability: A Systematic Review and Meta-analysis of 3275 Shoulders

BACKGROUND

Little consensus is available regarding the standard treatment for recurrent anterior instability of the shoulder. Typically, treatment selection has been based on training and tradition rather than the available evidence.

PURPOSE

This study aimed to compare the clinical outcomes between arthroscopic Bankart procedure and the Latarjet procedure in the treatment of recurrent anterior shoulder instability with emphasis on follow-up time.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials, Scopus, Ovid, and Web of Science up to January 2018 and included studies that compared arthroscopic Bankart versus Latarjet for treatment of anterior shoulder instability. Continuous data, such as operative time and patient-reported outcomes, were pooled as mean differences (MDs), whereas dichotomous data, such as recurrence, revision, redislocation, arthropathy, infection, and hematoma, were pooled as risk ratios (RRs), with 95% CIs.

RESULTS

Pooling data from 7 cohort studies (3275 patients) showed that arthroscopic Bankart was associated with a higher risk of redislocation (RR, 2.74; 95% CI, 1.48-5.06; P = .03), a higher risk of recurrence (RR, 2.87; 95% CI, 1.91-4.30; P < .0001), and a lower risk of infection (RR, 0.16; 95% CI, 0.06-0.43; P = .0002) compared with Latarjet, while the effect size did not favor arthroscopic Bankart or Latarjet in terms of Rowe score (MD, 0.22; 95% CI, -5.64 to 6.08; P = .94), revision (RR, 0.34; 95% CI, 0.08-1.39; P = .13), and hematoma (RR, 0.20; 95% CI, 0.03-1.19; P = .07). The effect estimate showed a pronounced advantage for Latarjet from 6 to 10 years postoperatively in terms of recurrence and redislocation (RR, 3.00; 95% CI, 1.98-4.56 and RR, 2.85; 95% CI, 1.51-5.38, respectively).

CONCLUSION

Our results showed that Latarjet had less risk of recurrence and redislocation with longer follow-up time. Both procedures were comparable in terms of Rowe score, the need for revision, and postoperative hematoma formation, whereas Bankart repair was associated with a lower risk of infection.

Arthroscopic Bankart repair with and without arthroscopic infraspinatus remplissage in anterior shoulder instability with a Hill-Sachs defect: a randomized controlled trial

BACKGROUND

The purpose of this study was to compare patient-reported and clinic outcomes between arthroscopic Bankart repair with (REMP) and without (NO REMP) arthroscopic infraspinatus remplissage in patients with recurrent anterior shoulder instability with a Hill-Sachs lesion and minimal glenoid bone loss.

METHODS

Patients 14 years or older with a recurrent anterior shoulder instability with the presence of an engaging Hill-Sachs defect (of any size) confirmed on computed tomography or magnetic resonance imaging were eligible to participate. Consented patients were randomized intraoperatively to NO REMP or REMP. Study visits were conducted preoperatively and 3, 6, 12, and 24 months postoperatively. The primary outcome was the Western Ontario Shoulder Instability score. Secondary outcomes included incidence of postoperative recurrent shoulder instability, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, range of motion, complications, and revision surgery. To compare groups, a mixed-effects linear model was used for continuous variables and a χ² or Fisher's exact test for categorical data. A Kaplan-Meier survival analysis assessed survival distribution between groups.

RESULTS

One hundred and eight patients were randomized to Bankart repair with (n = 54) or without (n = 54) remplissage. The mean follow-up was 26.5 months (21-53 months) and 24.3 months (23-64 months) for the REMP and NO REMP groups, respectively. Rates of postoperative recurrent instability were higher (P = .027) in the NO REMP group with 9 of 50 (18%) vs. 2 of 52 (4%) postoperative dislocations in the REMP group. There were no significant differences in patient-reported outcomes between groups at any time point. Survival curve distributions were also significantly different favoring REMP (χ² = 5.255, P = .022). There was a significant difference in rate of revision surgery between groups with 6 in the NO REMP and none in the REMP groups (P = .029). Post hoc, patients were noted to have a higher risk for re-dislocation if their Hill-Sachs lesion was ≥20 mm in width or ≥15% of humeral head diameter. One intraoperative complication was reported in the REMP group.

CONCLUSIONS

There is significantly greater risk of postoperative recurrent instability in patients who did not have a remplissage performed in conjunction with an arthroscopic Bankart repair for the treatment of traumatic recurrent anterior shoulder instability with Hill-Sachs lesions of any size and minimal glenoid bone loss (<15%) at 2 years postoperatively. Otherwise, there are no differences in patient-reported outcomes, complications, or shoulder function at 2 years postoperatively. In addition, the remplissage procedure has significantly lower rates of re-dislocation in high-risk patients with Hill-Sachs lesions ≥20 mm and/or ≥15% in size.

Arthroscopic Bankart Repair and Open Bristow Procedure in the Treatment of Anterior Shoulder Instability With Osseous Glenoid Lesions in Collision Athletes

Background:

Traumatic anterior shoulder instability in collision sports athletes often involves osseous glenoid lesions, which make surgical treatment challenging. High redislocation rates have been seen in collision sports athletes treated using arthroscopic Bankart repair.

Purpose:

To investigate the effectiveness of a combined arthroscopic Bankart repair and open Bristow procedure for the treatment of traumatic anterior shoulder instability in collision sports athletes, with a focus on osseous glenoid lesions.

Study Design:

Case series; Level of evidence, 4.

Methods:

We reviewed 149 shoulders in 141 competitive collision sports athletes (mean ± standard deviation age, 20.1 ± 4.1 years; 8 bilateral cases) who underwent a combined arthroscopic Bankart repair and open Bristow procedure with minimum 2 years of follow-up. Osseous Bankart lesions were arthroscopically reduced and fixed using a coracoid graft.

Results:

Clinical outcomes as indicated by mean Rowe score improved significantly from 50.0 preoperatively to 98.9 postoperatively (P < .001) at a median follow-up of 3.4 years (range, 2.5-7 years). There were 2 recurrent dislocations (1.3%), both of which had nonunion of the transferred coracoid. Osseous Bankart lesions were observed in 85 shoulders, and osseous glenoid lesions ≥10% of the diameter of the nonoperative side were found in 58 shoulders, including 24 off-track cases. Clinical outcomes were not significantly different between patients with a glenoid defect ≥10% and <10%. Nonunion of the transferred coracoid was observed in 16 shoulders (10.7%), which had inferior Rowe scores; however, we could not define any risk factors for nonunion, including patient characteristics or bone morphology. Postoperative computed tomography performed in 29 patients >1 year after surgery showed successful repair of the osseous glenoid lesions, with a restored glenoid articular surface in all cases. Significant pre- to postoperative increases were seen in glenoid diameter (mean, 13.1% [95% CI, 9.9%-16.3%]; P < .001) and area (mean, 10.6% [95% CI, 8.5%-12.7%]; P < .001).

Conclusion:

A combined arthroscopic Bankart repair and open Bristow procedure improved bone morphology and was a reliable surgical method for treating collision sports athletes with traumatic anterior shoulder instability involving osseous glenoid lesions.

Differences in Outcomes Between Anterior and Posterior Shoulder Instability After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis

Background:

The glenohumeral joint is one of the most frequently dislocated joints in the body, particularly in young, active adults.

Purpose:

To conduct a systematic review and meta-analysis to evaluate and compare outcomes between anterior versus posterior shoulder instability.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review was performed using the PubMed, Cochrane Library, and MEDLINE databases (from inception to September 2019) according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies were included if they were published in the English language, contained outcomes after anterior or posterior shoulder instability, had at least 1 year of follow-up, and included arthroscopic soft tissue labral repair of either anterior or posterior instability. Outcomes including return-to-sport (RTS) rate, postoperative instability rate, and pre- and postoperative American Shoulder and Elbow Surgeons (ASES) scores were recorded and analyzed.

Results:

Overall, 39 studies were included (2077 patients; 1716 male patients and 361 female patients). Patients with anterior instability had a mean age of 23.45 ± 5.40 years (range, 11-72 years), while patients with posterior instability had a mean age of 23.08 ± 8.41 years (range, 13-61 years). The percentage of male patients with anterior instability was significantly higher than that of female patients (odds ratio [OR], 1.36; 95% CI, 1.04-1.77; P = .021). Compared with patients with posterior instability, those with anterior instability were significantly more likely to RTS (OR, 2.31; 95% CI, 1.76-3.04; P < .001), and they were significantly more likely to have postoperative instability (OR, 1.53; 95% CI, 1.07-2.23; P = .018). Patients with anterior instability also had significantly higher ASES scores than those with posterior instability (difference in means, 6.74; 95% CI, 4.71-8.77; P < .001). There were no significant differences found in postoperative complications between the anterior group (11 complications; 1.8%) and the posterior group (3 complications; 1.6%) (OR, 1.12; 95% CI, 0.29-6.30; P = .999).

Conclusion:

Patients with anterior shoulder instability had higher RTS rates but were more likely to have postoperative instability compared with posterior instability patients. Overall, male patients were significantly more likely to have anterior shoulder instability, while female patients were significantly more likely to have posterior shoulder instability.

Arthroscopic Soft Tissue Stabilization With Selective Augmentations for Traumatic Anterior Shoulder Instability in Competitive Collision Athletes

BACKGROUND

Many surgeons prefer bony stabilization including Bristow or Latarjet procedures for shoulder instability in collision athletes, even though several potential complications have been reported. There has been a limited number of studies on the midterm outcomes of arthroscopic soft tissue stabilization for anterior shoulder instability in competitive collision athletes.

PURPOSE

To assess the outcomes of arthroscopic soft tissue stabilization in combination with selective augmentation procedures for collision athletes with traumatic anterior shoulder instability.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We retrospectively assessed rugby or American football players (<40 years old) who underwent arthroscopic Bankart or bony Bankart repair with selective augmentations (rotator interval closure and/or Hill-Sachs remplissage) for traumatic anterior shoulder instability between January 2012 and March 2017. Shoulders that required other bony procedures were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score and Subjective Shoulder Value sports score) were investigated.

RESULTS

This study included 113 shoulders in 100 patients with a mean age of 20 years (range, 15-36 years) at surgery. Rotator interval closure was performed on 36 shoulders in addition to Bankart repair, and rotator interval closure and Hill-Sachs remplissage were performed on 77 shoulders. The mean follow-up period was 44 months (range, 24-72 months). Of the 113 shoulders, 4 (3.5%) experienced postoperative dislocation, but there were no complications. A total of 93 athletes (93%) attained complete or near complete preinjury sports activity levels. The mean Rowe score significantly improved from 36 (range, 10-75) at presurgery to 96 (range, 35-100; P = .003) at postsurgery. The mean Subjective Shoulder Value sports score significantly improved after surgery, from a mean preoperative score of 22 (range, 0-50) to a postoperative score of 92 (range, 64-100; P = .002).

CONCLUSION

Our treatment strategy, where arthroscopic soft tissue stabilization was combined with selected augmentations, provided good clinical outcomes for competitive collision athletes in terms of low rates of recurrence and complication, a high rate of return to sports, and good shoulder function.

Patient Outcomes and Fear of Returning to Sports After Arthroscopic Bankart Repair With Remplissage

Background:

Although Bankart repair with remplissage is commonly performed to treat anterior shoulder instability, there is limited information on specific outcomes or patients’ fears regarding return to sports (RTS).

Purpose:

To study recurrence rates, pain, shoulder function, active range of motion (ROM), RTS rate, and patients’ fears and expectations for RTS after arthroscopic Bankart repair with remplissage for anterior shoulder instability. We compared these outcomes with those after Bankart repair alone.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective cohort study was carried out between 2007 and 2017 among patients who underwent arthroscopic Bankart repair with remplissage (group BR) and Bankart repair alone (group B). At the final follow-up, outcomes including recurrence, pain, shoulder function, active ROM, RTS rate, and fear toward RTS were assessed. The specific outcomes for RTS were evaluated based on 3 levels: return to normal life, RTS at any level (RTSA), and RTS at previous level (RTSP).

Results:

A total of 70 patients were included (29 in group BR and 41 in group B) with a mean 67.2 months of follow-up. Group BR demonstrated a significantly lower recurrence rate than did group B (0 vs 22.0%, respectively; P = .007) as well as higher postoperative Rowe score (92.8 ± 7.1 vs 83.3 ± 16.2, respectively; P = .005). There were no differences between the groups in postoperative visual analog scale for pain score, American Shoulder and Elbow Surgeons score, Oxford Shoulder Instability Score, or active ROM. The rates of RTSA (100% vs 84.2%; P = .03) and RTSP (77.8% vs 50.0%; P = .02) were higher in group BR than in group B, respectively, and significantly fewer patients in group BR reported fear of RTS (40.7% vs 63.2%; P = .04).

Conclusion:

In this study, recurrence rate, pain, shoulder function, active ROM, and RTS rate were satisfactory after arthroscopic Bankart repair with remplissage. Patients who underwent this procedure reported less fear toward RTS and higher rates of RTSA and RTSP than did those who undergo Bankart repair alone.

Glenoid erosion is a risk factor for recurrent instability after Hill-Sachs remplissage

AIMS

The aim of this study was to identify risk factors for recurrent instability of the shoulder and assess the ability to return to sport in patients with engaging Hill-Sachs lesions treated with arthroscopic Bankart repair and Hill-Sachs remplissage (ABR-HSR).

METHODS

This retrospective study included 133 consecutive patients with a mean age of 30 years (14 to 69) who underwent ABR-HSR; 103 (77%) practiced sports before the instability of the shoulder. All had large/deep, engaging Hill-Sachs lesions (Calandra III). Patients were divided into two groups: A (n = 102) with minimal or no (< 10%) glenoid bone loss, and B (n = 31) with subcritical (10% to 20%) glenoid loss. A total of 19 patients (14%) had undergone a previous stabilization, which failed. The primary endpoint was recurrent instability, with a secondary outcome of the ability to return to sport.

RESULTS

At a mean follow-up of four years (1.0 to 8.25), ten patients (7.5%) had recurrent instability. Patients in group B had a significantly higher recurrence rate than those in group A (p = 0.001). Using a multivariate logistic regression, the presence of glenoid erosion of > 10% (odds ratio (OR) = 35.13 (95% confidence interval (CI) 8 to 149); p = 0.001) and age < 23 years (OR = 0.89 (0.79 to 0.99); p = 0.038) were associated with a higher risk of recurrent instability. A total of 80 patients (78%) could return to sport, but only 11 athletes (65%) who practiced high-risk (collision or contact-overhead) sports. All seven shoulders which were revised using a Latarjet procedure were stable at a mean final follow-up of 36 months (11 to 57) and returned to sports at the same level.

CONCLUSION

Patients with subcritical glenoid bone loss (> 10%) and younger age (≤ 23 years) are at risk of failure and reoperation after ABR-HSR. Furthermore, following this procedure, one-third of athletes practicing high-risk sports are unable to return at their pre-instability level, despite having a stable shoulder. Cite this article: Bone Joint J 2021;103-B(4):718-724.

Comparative study of arthroscopic Bankart repair versus open Latarjet procedure for recurrent shoulder dislocation

OBJECTIVES

The primary aim of this study was to compare the clinical outcomes of patients undergoing arthroscopic Bankart repair and the open Latarjet procedure for recurrent dislocation of the shoulder. The secondary aims were to assess and compare the surgical cost, patient satisfaction, and complications, including recurrence and infection.

METHODS

We retrospectively compared the clinical outcomes of all consecutive patients undergoing either arthroscopic Bankart repair or the open Latarjet procedure from May 2015 to May 2018 with a minimum 2-year follow-up. Forty-one patients (32 men, 9 women) in the Bankart group and 40 patients (34 men, 6 women) in the Latarjet group were available for the final follow-up.

RESULTS

There were no statistically significant differences in the demographic parameters or clinical outcomes between the two groups. Functional satisfaction was higher with the Latarjet procedure. Bankart repair had a significantly higher operating cost than the Latarjet procedure. Three patients in the Bankart group and no patients in the Latarjet group developed recurrence.

CONCLUSION

Both procedures provided satisfactory clinical outcomes. However, the Latarjet group had a higher rate of functional satisfaction and lower operating cost, and there was a trend toward higher recurrence in the arthroscopic Bankart group.

Comparison between all-suture and biocomposite anchors in the arthroscopic treatment of traumatic anterior shoulder instability: A retrospective cohort study

Purpose

Suture anchors have revolutionized arthroscopic surgery, enabling direct soft tissue-to-bone repair. There are many types of anchors still used in arthroscopic shoulder operations. We sought to compare the clinical outcome of all-suture and biocomposite anchors when used in arthroscopic Bankart repair for patients suffering from anterior shoulder instability.

Methods

A single-center retrospective cohort study of 30 patients (mean age: 26.6 years, SD: 8.8 years, male/female ratio: 5/1, mean follow up: 28 months, SD: 23.8, range: 12-92) with anterior shoulder instability was conducted. Patients were divided into 2 groups based upon the type of suture anchors used for the Bankart repair: group A (14 patients) used only all-suture anchors and group B (16 patients) used only biocomposite anchors. Outcomes reported were postoperative dislocations, positive shoulder apprehension test, self-reported sense of shoulder instability, return to activities of daily living, return to sports, patient satisfaction and complications. Patient reported outcome measures (PROMs) used were the Rowe Score for Instability, Constant Shoulder Score, Walch Duplay Score, The American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Oxford Shoulder Instability Score and external rotation at 90° of arm abduction, external rotation at 0° of arm abduction, forward flexion, abduction, adduction and internal rotation.

Results

Rates of postoperative shoulder dislocation demonstrated no significant difference between the 2 groups (p > .05). Four postoperative dislocations happened, two in each group (14.3% and 12.5% for all suture only and biocomposite only groups, respectively), with three of them being traumatic. In addition, no significant differences were observed amongst groups regarding shoulder apprehension test (group A: 85.7% vs. group B: 93.8%), sense of shoulder instability (7.1% vs. 6.3%), return to activities of daily living (group A: 85.7% vs. group B: 93.8%), return to sports (group A: 85.7% vs. group B: 87.5%), patient satisfaction (moderate level: group A 21.4% vs. group B 12.5%), and PROMs.

Conclusion

The short-term failure rate and clinical/functional outcomes of arthroscopic Bankart repair using all-suture anchors is similar to the use of biocompatible anchors.

Level of evidence

Level III, retrospective cohort study.

Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long- term results

INTRODUCTION

Arthroscopic stabilization is a well-recognized surgical technique with a variable rate of failure reported between 0-35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate.

MATERIAL AND METHODS

41 patients that underwent arthroscopic shoulder stabilization for glenohumeral instability between 2001-2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognized in order to assess possible risk factors.

RESULTS

The overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent / good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery.

CONCLUSION

The arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favorable outcome, with a redislocation rate of 9% and low complication rate.

Simple versus horizontal mattress suture configuration in bankart repair

The purpose of this article was to compare the anatomy and biomechanics of different suture repair configurations for arthroscopic Bankart lesion repair. The horizontal mattress technique improves the restoration of labral height and decreases capsular strain in comparison to simple suture repairs. Further research examining the clinical outcomes of horizontal mattress suture technique is required for comparison with simple suture arthroscopic Bankart repairs.

Arthroscopic Bankart repair with an individualized capsular shift restores physiological capsular volume in patients with anterior shoulder instability

PURPOSE

Capsular volume reduction in the context of anterior arthroscopic shoulder stabilization represents an important but uncontrolled parameter. The aim of this study was to analyse capsular volume reduction by arthroscopic Bankart repair with an individualized capsular shift in patients with and without ligamentous hyperlaxity compared to a control group.

METHODS

In the context of a prospective controlled study, intraoperative capsular volume measurements were performed in 32 patients with anterior shoulder instability before and after arthroscopic Bankart repair with an individualized capsular shift. The results were compared to those of a control group of 50 patients without instability. Physiological shoulder joint volumes were calculated and correlated with biometric parameters (sex, age, height, weight and BMI).

RESULTS

Patients with anterior shoulder instability showed a mean preinterventional capsular volume of 35.6 ± 10.6 mL, which was found to be significantly reduced to 19.3 ± 5.4 mL following arthroscopic Bankart repair with an individualized capsular shift (relative capsular volume reduction: 45.9 ± 21.9%; P < 0.01). Pre-interventional volumes were significantly greater in hyperlax than in non-hyperlax patients, while post-interventional volumes did not differ significantly. The average shoulder joint volume of the control group was 21.1 ± 7.0 mL, which was significantly correlated with sex, height and weight (P < 0.01). Postinterventional capsular volumes did not significantly differ from those of the controls (n.s.).

CONCLUSION

Arthroscopic Bankart repair with an individualized capsular shift enabled the restoration of physiological capsular volume conditions in hyperlax and non-hyperlax patients with anterior shoulder instability. Current findings allow for individual adjustment and intraoperative control of capsular volume reduction to avoid over- or under correction of the shoulder joint volume. Future clinical studies should evaluate, whether individualized approaches to arthroscopic shoulder stabilization are associated with superior clinical outcome.

Glenoid bone resorption after Bankart repair: finite element analysis of postoperative stress distribution of the glenoid

BACKGROUND

There are various modifications of the Bankart repair, and postoperative changes to the glenoid morphology after the repair are reported. Among the various procedures performed, a decrease in the lateral glenoid diameter might be related to the surgery that involves removal of the articular cartilage and repair of the labrum-anterior inferior glenohumeral ligament complex on the glenoid surface. This is in contrast to cases without significant bony Bankart lesions that are not on the edge of the glenoid. Thus, this study aimed to compare glenoid rim stress after Bankart repair using 2 methods of finite element analysis: a method of removing the anteroinferior cartilage and repairing the glenohumeral ligament complex on the glenoid and a method of preserving the cartilage and repairing the glenohumeral ligament complex on the glenoid edge.

METHODS

Five preoperative computed tomography scans of patients with traumatic anterior instability who underwent arthroscopic Bankart repair were used. Two models simulating different surgical procedures were created as follows: in model G, a 5-mm-thick cartilage on the glenoid rim was removed between 2 and 7 o'clock, and the glenohumeral ligament complex was repaired on the medial edge of the glenoid bone where the cartilage was removed. In model E, the cartilage on the glenoid rim was not removed, and the glenohumeral ligament complex was repaired on the glenoid edge. The load stresses on the anteroinferior area of the glenoid after Bankart repair with models G and E were measured using finite element analysis.

RESULTS

The stress on the glenoid at 3-4 o'clock was 3.16 MPa in model G and 6.42 MPa in model E (P = .043). The stress at 4-5 o'clock was 1.68 MPa in model G and 4.53 MPa in model E (P = .043). The stress at 5-6 o'clock was 2.26 MPa in model G and 3.93 MPa in model E (P = .043).

CONCLUSION

Significantly lower load stresses were observed at the anteroinferior rim of the glenoid in model G than in model E.

Assessment and Trends in the Methodological Quality of the Top 50 Most Cited Articles in Shoulder Instability

Background:

Citation counts have often been used as a surrogate for the scholarly impact of a particular study, but they do not necessarily correlate with higher-quality investigations. In recent decades, much of the literature regarding shoulder instability is focused on surgical techniques to correct bone loss and prevent recurrence.

Purpose:

To determine (1) the top 50 most cited articles in shoulder instability and (2) if there is a correlation between the number of citations and level of evidence or methodological quality.

Study Design:

Cross-sectional study.

Methods:

A literature search was performed on both the Scopus and the Web of Science databases to determine the top 50 most cited articles in shoulder instability between 1985 and 2019. The search terms used included “shoulder instability,” “humeral defect,” and “glenoid bone loss.” Methodological scores were calculated using the Modified Coleman Methodology Score (MCMS), Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS) score.

Results:

The mean number of citations and mean citation density were 222.7 ± 123.5 (range, 124-881.5) and 16.0 ± 7.9 (range, 6.9-49.0), respectively. The most common type of study represented was the retrospective case series (evidence level, 4; n = 16; 32%) The overall mean MCMS, Jadad score, and MINORS score were 61.1 ± 10.1, 1.4 ± 0.9, and 16.0 ± 3.0, respectively. There were also no correlations found between mean citations or citation density versus each of the methodological quality scores.

Conclusion:

The list of top 50 most cited articles in shoulder instability comprised studies with low-level evidence and low methodological quality. Higher-quality study methodology does not appear to be a significant factor in whether studies are frequently cited in the literature.

CT image evaluation of one-screw fixation in the Latarjet procedure

Background

In the Latarjet procedure, two screws are used for secure fixation. However, when the graft is small, two-screw fixation is technically difficult. The purpose of this study was to evaluate the bone union of one-screw fixation on CT images.

Methods

Ten shoulders with anterior recurrent dislocation underwent the open Latarjet procedure using one-screw fixation combined with arthroscopic Bankart repair. The bone union and the graft position were evaluated on CT images at 3, 6, and 12 months after the operation.

Results

Seven of 10 shoulders showed bone union at 3 months after the operation. In two shoulders, the removal of cortex was insufficient, and bone union was observed at 6 months. In one shoulder, the distal part of the graft was not in contact with the glenoid, and bone union was observed at 12 months. In one shoulder, the graft was healed in a 70-degree-rotated position. The average thickness of the graft was 7.2 ± 1.0 mm.

Conclusion

One-screw fixation in the Latarjet procedure did not show non-union. Sufficient removal of the graft cortex and good contact were needed for early union.

Handedness-related outcome following arthroscopic shoulder stabilization

INTRODUCTION

Bankart's repair technique represents a standard procedure for arthroscopic shoulder stabilization with excellent functional outcomes. Information concerning handedness-related outcome is missing. Here, we compare the postoperative outcome following arthroscopic shoulder stabilization in relation to handedness, taking sex and age as covariates into account.

PATIENTS AND METHODS

Our retrospective dual-cohort study included 36 patients with dominant side shoulder instability (mean follow-up 33 months) and 31 patients with non-dominant side shoulder instability (mean follow-up 41 months), who underwent arthroscopic shoulder stabilization due to traumatic anterior-inferior shoulder instability. All had experienced recurrent dislocations preoperatively. The impact of handedness, and of age and sex as covariates on postoperative outcome was evaluated by the Rowe score, the apprehension test and self-reported VAS.

RESULTS

Postoperatively, the Rowe score of the dominant side (mean 81.8, median 97.5) and the non-dominant side (mean 84.8, median 100) was not different (P = 0.718). Likewise, the univariate analysis for handedness (P = 0.806), sex (P = 0.627) and age (P = 0.929) as well as multivariate analysis for handedness (P = 0.721), sex (P = 0.583) and age (P = 0.898) showed no difference. The apprehension test for dominant versus non-dominant side operated patients was not different (P = 0.194). The univariate and multivariate analysis for handedness (P = 0.202 and P = 0.387, respectively) and age (P = 0.322 and P = 0.310, respectively) revealed no difference. However, the univariate and multivariate analysis for sex (P = 0.007 and P = 0.013, respectively) showed a difference. In relation to handedness, the results for the validated self-reported pain (rest pain P = 0.696, load-dependent pain P = 0.332) and surgery outcome satisfaction (P = 0.912) VAS were not different.

CONCLUSIONS

Patients with shoulder instability, who underwent arthroscopic Bankart repair for stabilization of their dominant or non-dominant shoulder showed no handedness-related difference in postoperative outcome based on Rowe score, apprehension test and self-reported VAS. For the orthopedic practice, this suggests that handedness is not a risk factor for patients outcome.

LEVEL OF EVIDENCE

Level IV, cohort study.

Concomitant rotator cuff repair and instability surgery provide good patient-reported functional outcomes in patients aged 40 years or older with shoulder dislocation

Background

Recurrent anterior shoulder dislocation in patients aged ≥ 40 years is not as rare as once thought. The mechanism of instability in this patient population is different—more likely to be attributed to rotator cuff pathology—compared with that in younger individuals. With an increasingly aging active population, surgical management has a rising role in preventing morbidity associated with recurrent instability. Our purpose was to evaluate outcomes of anterior shoulder instability repair (ie, Bankart or bony Bankart repair) with and without rotator cuff repair (RCR) in patients aged ≥ 40 years.

Methods

We conducted a retrospective chart review of all patients aged ≥ 40 years who underwent surgical repair for anterior shoulder instability from 2008-2016. Patients were categorized into 4 cohorts: Bankart repair only, bony Bankart repair only, Bankart repair with concomitant RCR, and bony Bankart repair with concomitant RCR. Demographic and history-of-instability data were collected. Clinical and functional outcomes assessed included the Single Assessment Numeric Evaluation score, American Shoulder and Elbow Surgeons score, Penn Shoulder Score, visual analog scale score for pain, Western Ontario Shoulder Instability Index score, and patient satisfaction score.

Results

A total of 146 patients were included in this study, with 103 patients (71%) having ≥2-year outcome scores. Outcome scores were not significantly different among groups. For patients who underwent Bankart repair only, bony Bankart repair only, Bankart repair with RCR, and bony Bankart repair with RCR, the Single Assessment Numeric Evaluation scores were 80.8 ± 19.7, 90.0 ± 10.7, 79.3 ± 29.4, and 87.2 ± 10.6, respectively (P = .284); American Shoulder and Elbow Surgeons scores, 83.8 ± 19.7, 92.4 ± 17.4, 82.5 ± 25.6, and 85.6 ± 12.7, respectively (P = .114); Penn Shoulder Scores for function, 84.5 ± 17.9, 90.9 ± 15.3, 83.6 ± 25.1, and 95.7 ± 13.0, respectively (P = .286); and Western Ontario Shoulder Instability Index scores, 481.0 ± 519.5, 292.1 ± 414.3, 548.9 ± 690.5, and 320.6 ± 258.7, respectively (P = .713). Age at the time of surgery significantly differed between cohorts (P < .001). No patients had recurrence of instability during the study period.

Conclusion

Similar functional outcomes can be achieved in the surgical management of anterior instability in patients aged ≥ 40 years. Rotator cuff tears should be suspected and repaired in patients with anterior instability, especially those aged ≥ 50 years.

Location of the Suture Anchor in Hill-Sachs Lesion Could Influence Glenohumeral Cartilage Quality and Limit Range of Motion After Arthroscopic Bankart Repair and Remplissage

BACKGROUND

No study has reported clinical evidence for cartilage change in the glenohumeral joint or the cause of loss in range of motion (ROM) after arthroscopic Bankart repair with remplissage technique (BR).

PURPOSE

To investigate the postoperative features of glenohumeral joint cartilage, ROM, and anchor placement for remplissage at a minimum of 2 years of follow-up after BR and to analyze the correlations.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A total of 21 patients who underwent BR received follow-up for a minimum of 2 years. At both preoperative assessment and final follow-up, passive shoulder ROM, Oxford Shoulder Instability Score, Simple Shoulder Test score, and Single Assessment Numerical Evaluation score were assessed. All patients underwent 3.0-T magnetic resonance imaging (MRI) examination at final follow-up. The clinical outcomes, glenohumeral cartilage or Hill-Sachs lesion-related MRI parameters, and their potential correlations were analyzed.

RESULTS

The mean follow-up was 55.0 months (range, 24-119 months). Compared with preoperative assessment, all functional scores significantly improved (P < .001). At the final follow-up, a significant ROM loss (>15°) of external rotation (ER) at the side (ER₀) was found in 12 patients, among whom 8 patients had significant ROM loss of ER at 90° of abduction as well. Further, 12 patients with decreased ER had significantly higher signal intensity of cartilage on the anterior, middle, and posterior humeral head (anterior, P = .002; middle, P < .001; posterior, P < .001) than 9 patients with normal ER. The ratio of the width of the remplissage anchor to the diameter of the humeral head (w:d ratio) was significantly greater (P = .031) in the decreased ER group than in the normal ER group. Correlation analysis showed that signal intensity on the posterior humeral head and ER₀ loss (ΔER₀) had a significantly positive correlation (r = 0.516; P = .034), while the w:d ratio and ΔER₀ had a significantly positive correlation (r = 0.519; P = .039).

CONCLUSION

At a minimum of 2 years of follow-up, patients who underwent BR showed significant clinical improvement compared with preoperative assessment, except for limitations in ER. The glenohumeral cartilage degeneration (higher signal intensity) after BR had a significantly positive correlation with the postoperative ER loss, which was found to be associated with a relatively medial placement of the remplissage anchor.

Functional outcome and tendon integrity of rotator cuff reconstruction after primary traumatic glenohumeral dislocation

INTRODUCTION

Rotator cuff tears (rct) subsequent to glenohumeral dislocation are relevant concomitant injuries, can lead to impaired shoulder function and increase risk of recurrent dislocation.

AIM

The aim of this study was to determine the functional outcome, recurrent dislocation rate and tendon integrity after rotator cuff repair after primary traumatic shoulder dislocation.

MATERIALS AND METHODS

In this retrospective case series, 23 patients (age 56.4 years ± 6.3) who underwent a rotator cuff reconstruction after primary traumatic shoulder dislocation with confirmed combination of full-thickness RCT and Bankart lesion were enrolled after a minimum follow-up of 2 years. Clinical outcome (age and gender adjusted Constant Murley Score (CMS), DASH, Rowe Score) (n = 23) and sonographic tendon integrity (n = 19) were studied.

RESULTS

After a mean follow-up of 58 ± 32 months, a CMS of 85.1% ± 14.7, DASH of 14.2 ± 20.5, and Rowe Score of 82.4 ± 15.2 indicated good functional outcome. In 4 of 19 patients (21.1%) a re-tear was found during sonographic evaluation. In 3 cases (13%), a revision was performed (2 × stiff shoulder, 1 × postoperative infection). One patient had a single traumatic re-dislocation (4.3%).

CONCLUSIONS

Patients undergone reconstruction of the rotator cuff following a primary traumatic shoulder dislocation can achieve good functional results and a low rate of recurrent dislocation. Postoperative tendon integrity is comparable with known data about non traumatic tears.