Comparison of Bristow procedure and Bankart arthroscopic method as the treatment of recurrent shoulder instability

BACKGROUND

Anterior shoulder dislocation is the most common major joint dislocation. In patients with recurrent shoulder dislocation, surgical intervention is necessary. In this study, two methods of treatment, Bankart arthroscopic method and open Bristow procedure, were compared.

MATERIALS AND METHODS

This clinical trial survey had been done in the orthopedic department of Alzahra and Kashani hospitals of Isfahan during 2008-2011. Patients with recurrent anterior shoulder dislocation who were candidates for surgical treatment were randomly divided into two groups, one treated by Bankart arthroscopic technique and the other treated by Bristow method. All the patients were assessed after the surgery using the criteria of ROWE, CONSTANT, UCLA, and ASES. Data were analyzed by SPSS software.

RESULTS

Six patients (16.22%) had inappropriate condition with ROWE score (score less than 75); of them, one had been treated with Bristow and five with Bankart (5.26 vs. 27.78). Nine patients (24.32%) had appropriate condition, which included six from Bristow group and three treated by Bankart technique (31.58 vs. 16.67). Finally, 22 patients (59.46%) showed great improvement with this score, which included 12 from Bristow and 10 from Bankart groups (63.16 vs. 55.56). According to Fisher's exact test, there were no significant differences between the two groups (P = 0.15).

CONCLUSION

The two mentioned techniques did not differ significantly, although some parameters such as level of performance, pain intensity, use of analgesics, and range of internal rotation showed more improvement in Bristow procedure. Therefore, if there is no contraindication for Bristow procedure, it is preferred to use this method.

Functional and imaging outcomes of arthroscopic simultaneous rotator cuff repair and bankart repair after shoulder dislocations

BACKGROUND

Previous studies have investigated outcomes of simultaneous rotator cuff (RC) repair and superior labral injury repair; however, there is limited information in the literature on outcomes of simultaneous RC repair and Bankart lesion repair after acute shoulder dislocations.

PURPOSE

To determine functional and imaging outcomes of simultaneous arthroscopic RC repair and Bankart repair after acute shoulder dislocations and to compare functional outcomes to contralateral, asymptomatic shoulders.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients who underwent arthroscopic simultaneous RC repair and Bankart repair with a minimum of 2 years' follow-up were recruited. All patients had suffered an acute shoulder dislocation. The American Shoulder and Elbow Surgeons (ASES), Constant-Murley, and Short Form (SF)-36 scores were obtained. The affected shoulder also underwent ultrasound imaging to assess the integrity of the RC.

RESULTS

Thirteen patients (mean age, 58.8 ± 11.2 years; mean follow-up, 38.5 ± 12.3 months) were recruited. In a comparison of the affected versus unaffected shoulder, there were no significant differences in the mean ASES score (89.7 ± 12.6 vs 95.0 ± 6.7, respectively), mean Constant score (80.5 ± 18.9 vs 86.8 ± 7.9, respectively), or mean abduction strength (15.4 ± 6.4 lb vs 15.4 ± 5.2 lb, respectively) (P > .05). The mean SF-36 physical component summary was 48.4. According to ultrasound imaging, there were persistent/recurrent full-thickness tears in 4 patients, and 1 patient had a new full-thickness tear. At follow-up, patients with full-thickness RC tears in the affected shoulder compared with their unaffected shoulder showed similar mean ASES scores (90.9 ± 11.8 vs 97.6 ± 4.3, respectively), mean Constant scores (77.8 ± 20.3 vs 84.8 ± 7.2, respectively), and mean abduction strength (11.5 ± 5.3 lb vs 12.6 ± 4.5 lb, respectively) (P > .05).

CONCLUSION

After simultaneous arthroscopic repair of the RC and a Bankart lesion in patients after shoulder dislocations, the affected extremity had similar functional outcomes compared to the noninjured, asymptomatic side at a mean of 3 years after surgery. Persistent or recurrent RC tears involving the operative extremity were common, but they did not significantly affect functional outcomes in this small study.

Effect of Bankart repair on the loss of range of motion and the instability of the shoulder joint for recurrent anterior shoulder dislocation

BACKGROUND

Bankart repair postoperative complications include loss of shoulder motion and shoulder instability. The primary reason that postoperative complications develop may be excessive imbrication of the anterior band of the inferior glenohumeral ligament (AIGHL) or inadequate repair position. The purpose of this study was to quantitatively evaluate the influence of inadequate repair by computer simulation for a normal shoulder joint.

METHODS

Magnetic resonance images of 10 normal shoulder joints were acquired for 7 positions every 30° from the maximum internal rotation to the maximum external rotation with the arm abducted at 90°. The shortest 3-dimensional path of the AIGHL in each rotational orientation was calculated. We used computer simulations to anticipate the loss of motion and instability by changing the AIGHL length and insertion sites on the glenoid.

RESULTS

The AIGHL length measured 50 ± 5 mm at the maximum external shoulder rotation. AIGHL shortening by 3, 6, and 9 mm made the angle of maximum external rotation 80°, 68°, and 54°, respectively. A superior deviation of 3, 6, and 9 mm on the glenoid insertion resulted in a maximum external rotation angle of 85°, 79°, and 77°. An inferior deviation of 3, 6, and 9 mm produced humeral head translation of 1.7, 2.9, and 3.6 mm.

CONCLUSION

Simulation of both excessive imbrication and deviation of the insertion position led to quantitative prediction of the resulting loss of motion and instability. These findings will be useful for anticipating complications after Bankart repair.

LEVEL OF EVIDENCE

Basic science study, computer modeling, imaging.

Morphological Characteristics of the Repaired Labrum According to Glenoid Location and Its Clinical Relevance After Arthroscopic Bankart Repair: Postoperative Evaluation With Computed Tomography Arthrography

BACKGROUND

There have been no studies on the postoperative morphological characteristics of the restored labrum at different glenoid locations and its clinical relevance after arthroscopic Bankart repair with suture anchors.

PURPOSE

To analyze the morphological characteristics of the restored labrum at different locations of the glenoid and their relevance to clinical outcomes as well as affecting factors and to trace the inserted suture anchors after arthroscopic Bankart repair using computed tomography arthrography (CTA).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 46 patients (mean age, 26.5 ± 6.8 years) who underwent arthroscopic Bankart repair with absorbable suture anchors were enrolled in this study. Patients underwent CTA preoperatively and 6 months postoperatively as well as functional outcome evaluation preoperatively and at the last follow-up (>24 months) with the Rowe score and visual analog scale for pain. Labral height and width were measured on conventional axial CTA images at the 3-, 4-, and 5-o'clock positions twice by 2 raters. The postoperative measurements were also compared with those of the healthy anterior labrum, acquired from the same CTA examination of 32 consecutive patients (mean age, 26.5 ± 8.5 years) with superior labral lesions in the same study period. The postoperative difference in the measurements and between clock positions, and the relationship between the measurements and the clinical factors and functional outcomes, were evaluated. In addition, the locations of all suture anchors were traced on each CTA image, and outcomes according to the locations of the most inferior suture anchors were assessed.

RESULTS

The interobserver and intraobserver reliabilities of measurements at each location were excellent (Pearson correlation coefficient = 0.773-0.988). Of the 46 patients, 2 (4.35%) had redislocations after surgery. Postoperative labral height and width were significantly increased at all locations (all P < .001) up to a level similar to the healthy anterior labrum, with significantly larger values at the inferior location compared with the superior location (all P < .05). Patients who had a greater frequency of dislocations before surgery showed a lower postoperative labral height at the 5-o'clock position (P = .012), and this correlated with postoperative instability and poor functional outcomes by the Rowe score (P = .036). In most patients (41/46; 89.1%), the tips of the lowest suture anchors perforated the far cortex, and these anchors were mostly located below the 5-o'clock position (32/41; 78.0%). However, perforation of the far cortex did not affect functional outcomes.

CONCLUSION

Surgeons should be cautious of restoring labral height at the inferior glenoid location for successful arthroscopic Bankart repair. In addition, attention should be given to inserting the lowest suture anchor regardless of clinical significance.

Validity of arthroscopic measurement of glenoid bone loss using the bare spot

PURPOSE

Our aim was to test the validity of using the bare spot method to quantify glenoid bone loss arthroscopically in patients with shoulder instability.

METHODS

Twenty-seven patients with no evidence of instability (18 males, nine females; mean age 59.1 years) were evaluated arthroscopically to assess whether the bare spot is consistently located at the center of the inferior glenoid. Another 40 patients with glenohumeral anterior instability who underwent shoulder arthroscopy (30 males, ten females; mean age 25.9 years) were evaluated for glenoid bone loss with preoperative three-dimensional computed tomography (3D-CT) and arthroscopic examination. In patients without instability, the distances from the bare spot of the inferior glenoid to the anterior (Da) and posterior (Dp) glenoid rim were measured arthroscopically. In patients with instability, we compared the percentage glenoid bone loss calculated using CT versus arthroscopic measurements.

RESULTS

Among patients without instability, the bare spot could not be identified in three of 27 patients. Da (9.5±1.2 mm) was smaller than Dp (10.1±1.5 mm), but it was not significantly different. However, only 55% of glenoids showed less than 1 mm of difference between Da and Dp, and 18% showed more than 2 mm difference in length. The bare spot could not be identified in five of 40 patients with instability. Pearson's correlation coefficient showed significant (P<0.001) and strong (R (2)=0.63) correlation in percentage glenoid bone loss between the 3D-CT and arthroscopy method measurements. However, in ten shoulders (29%), the difference in percentage glenoid bone loss between 3D-CT and arthroscopic measurements was greater than 5%.

CONCLUSION

The bare spot was not consistently located at the center of the inferior glenoid, and the arthroscopic measurement of glenoid bone loss using the bare spot as a landmark was inaccurate in some patients with anterior glenohumeral instability.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Arthroscopic subscapularis bankart technique as a salvage procedure for failed anterior shoulder stabilization

BACKGROUND

Shoulder instability is a relatively common problem. Even with contemporary surgical techniques, instability can recur following both open and arthroscopic fixation. Surgical management of capsular insufficiency in anterior shoulder stabilization represents a significant challenge, particularly in young, active patients. There are a limited number of surgical treatment options. The Laterjet technique can present with a number of intraoperative challenges and postoperative complication.

DESCRIPTION OF TECHNIQUE

We report an arthroscopic subscapularis tenodesis technique as a salvage procedure for challenging glenohumeral instability cases. Sutures are passed through the subscapularis tendon and capsule before they are tied as one in the subdeltoid psace. The rotator interval is closed with superior and medial advancement of anterior and inferior tissue. This technical note carefully describes this procedure with useful technical tips, illustrations, and diagrams.

PATIENTS AND METHODS

Two clinical cases are described involving patients with recurrent instability following failed surgery who were successfully managed with this procedure.

RESULTS

Both cases described resulted in improved shoulder stability, range of motion, and function following management with this surgical technique. This arthroscopic subscapularis tenodesis procedure is proposed as a useful alternative repair technique for cases of recurrent instability after failed surgery with isolated capsular insufficiency.

CONCLUSION

It is believed that this arthroscopic subscapularis tenodesis technique can potentially provide similar outcomes to open bone block stabilization procedures, while reducing the risks associated with those procedures.

Early outcome of arthroscopic Bankart's repair for recurrent traumatic anterior shoulder instability

BACKGROUND/OBJECTIVES

Despite the improvements in the methods of arthroscopic stabilization of anterior shoulder instability, a recurrence rate of as high as 30% is reported in the literature. In this context, we report the outcome of arthroscopic Bankart repair in anterior shoulder instability, with the use of bio-absorbable suture anchors for patients that were followed up for at least two years from the date of surgery. The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. We would like to report the 2-year clinical outcomes of bio-absorbable suture anchors used in traumatic anterior dislocations of the shoulder.

METHODS

Data from 79 shoulders in 74 patients were collected over 4 years (2005-2009). Each patient was followed up over a period of 2 years. The patients underwent arthroscopic Bankart repair using bio-absorbable suture anchors for their anterior shoulder instability. These surgeries were performed at a single institution by a single surgeon over the time period. The patients were assessed with two different outcome measurement tools. The University of California at Los Angeles (UCLA) shoulder rating scale and the Simple Shoulder Test (SST) score. The scores were calculated before surgery and at the 2-year follow-up. The recurrence rates, range of motion as well post-operative function and return to sporting activities were evaluated.

RESULTS

SST results from the 12 domains showed a significant improvement from a mean of 6.1 ± 3.1 to 11.1 ± 1.8 taken at the 2-year follow-up (p < 0.0001). Data from the UCLA scale showed a pre and post-operative mean of 20.2 ± 5.0 and 32.4 ± 4.6 respectively (p < 0.0001). 34 had excellent post-operative scores, 35 had good scores, 1 had fair score and 3 had poor scores. 75% of the patients returned to sports while 7.6% developed a recurrence of shoulder dislocation or subluxation.

CONCLUSION

Arthroscopic Bankart repair with the use of suture anchors is a reliable treatment method, with good clinical outcomes, excellent post-operative shoulder motion and low recurrence rates.