Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study

The effect of subscapularis tenotomy in athletes operated on for recurrent anterior shoulder dislocation

PURPOSE

Some authors consider preservation of the subscapularis tendon as one of the most important elements for a successful long-term outcome in patients operated on with open capsulorrhaphy for recurrent anterior shoulder dislocation. The purpose of this study was to evaluate whether vertical tenotomy of the subscapularis tendon might affect internal rotation strength recovery in patients operated on with open capsulorrhaphy for recurrent anterior shoulder dislocation.

METHODS

Ninety-six patients were retrospectively followed up at a mean of 72.5 months. They underwent clinical evaluation, Rowe and Walch-Duplay scoring scales, the Visual Analog Scale (VAS), and dynamometric measurements (side-to-side) of internal and external rotation, forward elevation, and abduction. All patients were athletes: 25% were practising risk-free sports, 44% contact sports, 14.5% sports with cocking of the arm, and 14.5% high-risk sports activities.

RESULTS

Five (5.2%) recurrences were registered, and all patients returned to pre-operative sports activity. The Rowe score was 98.12, the Walch-Duplay score 92.25, and the VAS score 0.1. Dynamometric assessment showed no significant differences (side-to-side) in internal rotation (p = 0.34), external rotation (p = 0.9), flexion (p = 0.7), and abduction (p = 0.7). Dominant arms showed better results than non-dominant arms (p < 0.01).

CONCLUSION

Complete tenotomy of the subscapularis tendon does not seem to negatively affect internal rotation strength recovery or external rotation movement in athletes.

Rotator cuff muscular integrity after arthroscopic revision of a Bankart repair

INTRODUCTION

Recurrent shoulder instability after arthroscopic Bankart repair is still a common complication. For primary Bankart repair studies have shown that the rotator cuff can recover completely. The ability of muscles to regenerate after arthroscopic revision Bankart repair (ARBR) has not been studied. Does the ARBR using a three-portal method allows complete muscle integrity compared with an uninjured imaging control group (ICG)?

MATERIALS AND METHODS

Twenty-two (1 female, 21 males) physically active patients (mean age at follow-up 28.5 ± 7.1 years; mean follow-up 27.5 months ± 8.5) were assessed. ARBR with a three-portal method was carried out in all patients according to previous primary arthroscopic stabilization of the shoulder (revision Bankart group). Muscle atrophy of the subscapularis muscle (SSC), supraspinatus muscle (SSP) and infraspinatus muscle (ISP) was assessed by making lateral and vertical measurements by magnetic resonance imaging (MRI). Fatty infiltration was detected by standardized assessment from variations in intensity. Detailed clinical examination of the rotator cuff was carried out. MRI assessment was compared with that of a control group of 22 healthy volunteers of same age and activity level (ICG).

RESULTS

For the SSC, no muscle impairment was noted compared with the ICG [superior atrophy index (sAI_SSC), p = 0.439; inferior atrophy index (iAI_SSC), p = 0.555; superior fatty infiltration index (sFDI_SSC), p = 0.294; inferior fatty infiltration index (iFDI_SSC), p = 0.62]. In investigation of the SSP and ISP, fatty infiltration was not shown (FDI_SSP, p = 0.454; sFDI_ISP, p = 0.504), though persistent muscle atrophy was found even > 2 years after surgery compared with the ICG (AI_SSP, p = 0.0025; sAI_ISP, p = 0.0009; iAI_ISP, p = 0.0004).

CONCLUSION

ARBR using a three-portal method allowed good muscular integrity compared with the ICG, but with persistent slight muscular atrophy of the SSP and ISP.

Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability: Indications and Outcomes

PURPOSE OF REVIEW

Arthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability.

RECENT FINDINGS

Improvements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome. When indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.

Open versus arthroscopic surgical treatment for anterior shoulder dislocation: a comparative systematic review and meta-analysis over the past 20 years

BACKGROUND

The purpose of this study was to perform a meta-analysis comparing open and arthroscopic surgery for the treatment of anterior shoulder instability by analyzing comparative studies during 2 different time intervals during the last 20 years.

METHODS

We conducted a systematic review of MEDLINE, Embase, Scopus, and Google Scholar. Two groups were created by dividing studies according to the year of publication, those published from 1995 to 2004 or from 2005 to 2015. Publication bias and risk of bias were assessed using the Cochrane Collaboration's tools. Heterogeneity was assessed using the I² statistics.

RESULTS

A total of 22 studies (n = 1633) met the eligibility criteria. Comparison of the pooled estimate for all of these studies demonstrated no significant differences (P = .64) in clinical outcomes between open and arthroscopic shoulder stabilization. However, studies published from 1995 through 2004 demonstrated significant differences (P = .015) in recurrence rates favoring open surgery. In contrast, no significant differences (P = .09) in recurrence rates were observed for studies published from 2005 through 2015. The pooled estimate for all studies in both groups demonstrated significant differences (P = .001) in external rotation deficits between open and arthroscopic shoulder stabilization favoring arthroscopic surgery.

CONCLUSION

Despite advances in surgical techniques and devices during the last 20 years, either open or arthroscopic surgical treatment of anterior shoulder dislocation results in similar clinical outcomes. The recurrence rate for arthroscopic surgical stabilization has only marginally decreased, from 16.8% to 14.2%. However, during the earlier decade from 1995 through 2004, patients treated with arthroscopic surgery had twice the risk of recurrence compared with an open procedure.

Controversies in the Surgical Management of Shoulder Instability: Open vs Arthroscopic Procedures

BACKGROUND

Traumatic anterior instability of the shoulder is a common condition associated with a high recurrence rate in young adults. Operative treatment reduces the risk of recurrence. Several studies have compared arthroscopic and open shoulder instability repair. The purpose of this paper is to perform a review of the literature where both techniques are compared in the repair of the anterior shoulder instability without bone loss.

METHODS

Prior to arthroscopy, recurrent dislocations were managed by open repair. There have been many studies documenting low recurrence rates after open Bankart stabilization. Initially, arthroscopic fixation reported high failure rates.

RESULTS

In the last 20 years, the development of arthroscopic stabilization for recurrent anterior instability has improved failure rates. In comparison with open techniques, arthroscopic procedures have the advantages of decreased morbidity rate, early functional rehabilitation and improved range of motion.

CONCLUSION

The available evidence does not show a statistically significant difference in outcome measures between arthroscopic and open repair for the treatment of recurrent anterior shoulder instability. Given the similar results between the 2 groups, differences in length of hospital stay and cost to the patient and society point to arthroscopic repair as the more judicious treatment approach.

Single anterior portal: A better option for arthroscopic treatment of traumatic anterior shoulder instability?

Objective

The aim of this study was to compare single and double anterior portal techniques in the arthroscopic treatment of traumatic anterior shoulder instability.

Methods

A total of 91 cases who underwent arthroscopic Bankart repair for anterior shoulder instability were reviewed. The patients were divided into 2 groups as Group 1 (47 male and 2 female; mean age: 25.8 ± 6.8) for arthroscopic single anterior portal approach and Group 2 (41 male and 1 female; mean age: 25.4 ± 6.6) for the classical anterior double portal approach. The groups were compared for clinical scores, range of motion, analgesia requirement, complications, duration of surgery, cost and learning curve according to a short questionnaire completed by the relevant healthcare professionals.

Results

No statistically significant difference was found between the 2 groups in terms of pre-operative and post-operative Constant and Rowe Shoulder Scores, range of motion and complications (p > 0.05). In Group 2 patients, the requirement for post-operative analgesics was significantly higher (p < 0.001), whereas the duration of surgery was statistically significantly shorter in Group 1 (p < 0.001). In the assessment of the questionnaire, it was seen that a single portal anterior approach was preferred at a higher ratio (p = 0.035). The cost analysis revealed that the cost was 5.7% less for patients with a single portal.

Conclusion

In the arthroscopic treatment of traumatic anterior shoulder instability accompanied by a Bankart lesion, the anterior single portal technique is as successful in terms of clinical results as the conventional double portal approach. The single portal technique has advantages such as less postoperative pain, a shorter surgical learning curve and lower costs.

Level of Evidence

Level III, Therapeutic study.

Trends in Surgical Management of Shoulder Instability

Background:

Optimal surgical management of anterior shoulder instability remains controversial. There is a need to assess the most recent trends for primary and revision shoulder stabilization surgery using a national database significantly larger than those previously utilized.

Hypothesis:

Most shoulder stabilization procedures are performed arthroscopically. Examining revision procedures, we hypothesized that open procedures would result in decreased revision stabilizations compared with arthroscopic procedures and that most revision procedures would be open Bankart or bone transfer procedures regardless of the index procedure technique.

Study Design:

Descriptive epidemiology study.

Methods:

The MarketScan Database was searched using International Classification of Diseases–Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes to identify patients who underwent any shoulder stabilization procedure between 2008 and 2012. Regression analysis was used to evaluate trends between patient groups. The Cochran-Armitage trend test was used to identify differences in trends seen yearly. Odds ratios (ORs) were calculated to compare the likelihood of undergoing a revision stabilization procedure.

Results:

A total of 66,564 shoulder stabilization procedures were identified from 2008 through 2012: 60,248 arthroscopic stabilization procedures (90.5%) and 6316 open stabilization procedures (9.5%), including 1623 bone block procedures. Arthroscopic stabilization procedures increased in total number and percentage of all procedures in each year of the study. Bone block procedures increased in number each year, although other open procedures decreased during the study period. Males underwent more stabilization procedures, while patients between the ages of 10 and 19 years were most likely to undergo any procedure. Patients who underwent bone block stabilization were significantly less likely to undergo a second stabilization procedure during the study period when compared with open Bankart repair (OR, 0.582; 95% CI, 0.405-0.836; P < .05) and arthroscopic Bankart repair (OR, 0.587; 95% CI, 0.418-0.824; P < .05). No statistically significant difference in revision stabilization was seen when comparing arthroscopic versus open Bankart repair (OR, 0.934; 95% CI, 0.863-1.139).

Conclusion:

Although the number of arthroscopic shoulder stabilization surgeries continues to increase, our data show a consistent increase, not seen in prior studies, in the number of bone block procedures. Contrary to some studies, there was no significant difference in the likelihood of a second procedure between patients initially undergoing arthroscopic compared with open Bankart repair.

Arthroscopic Panlabral Repair With Remplissage of Hill-Sachs Lesion

Recurrent shoulder instability in young contact athletes has been well established. The importance of bipolar bone loss in instability has come to the forefront in terms of proper management of this condition. It remains controversial, however, which patients would be better served with an arthroscopic versus open procedure and when additional procedures may reduce the risk of failure (i.e., remplissage). We present our arthroscopic technique of a panlabral repair with concomitant remplissage using the double-pulley technique. The purpose of this article is to provide insight into obtaining superior visualization while reviewing surgical pearls and pitfalls to efficiently perform a panlabral repair and remplissage.

Recurrent Shoulder Instability in a Young, Active, Military Population and Its Professional Implications

Background:

Shoulder instability is a topic of significant interest within the sports medicine literature, particularly regarding recurrence rates and the ideal treatment indications and techniques. Little has been published specifically addressing the occupational implications of symptomatic recurrent shoulder instability.

Hypothesis:

Previous arthroscopic repair will continue to be a significant predisposing factor for recurrent instability in a young, active population, and that recurrent instability may have a negative effect on college graduation and postgraduate occupational selection.

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

We conducted a retrospective review of approved medical waivers for surgical treatment of anterior shoulder dislocation or instability prior to matriculation at the US Military Academy or the US Naval Academy for the graduating classes of 2010 to 2013. Statistical analysis was performed to determine the incidence and risk factors for recurrence and to determine the impact on graduation rate and occupation selection.

Results:

Fifty-nine patients were evaluated; 34% developed recurrent anterior instability. Patients with previous arthroscopic repair had a significantly higher incidence of recurrence (38%, P = 0.044). Recurrent shoulder instability did not significantly affect graduation rates or self-selected occupation (P ≥ 0.05).

Conclusion:

There is a significant rate of recurrent shoulder instability after primary surgical repair, particularly among young, active individuals. In addition, arthroscopic repair resulted in a significantly higher recurrence rate compared with open repair in our population. Surgical repair for shoulder instability should not necessarily preclude young individuals from pursuing (or being considered for) occupations that may place them at greater risk of recurrence.

Clinical Relevance:

The risk of recurrent instability is greater than the rate typically described, which may suggest that some subpopulations are at greater risk than others. A unique data point regarding instability is the effect on occupation selection.

Arthroscopic Subscapularis Augmentation of Bankart Repair in Chronic Anterior Shoulder Instability With Bone Loss Less Than 25% and Capsular Deficiency: Clinical Multicenter Study

PURPOSE

To assess the short-term outcomes of the arthroscopic subscapularis augmentation (ASA) technique, consisting of a tenodesis of the upper third of the subscapularis tendon and a Bankart repair, and its effect on shoulder external rotation.

METHODS

Patients selected for this study were involved in contact sports, with a history of traumatic recurrent shoulder dislocations and a minimum of 2-year follow-up. Inclusion criteria were patients with glenoid bone loss (GBL) ranging from 5% to 25%, anterior capsular deficiency, and Hill-Sachs lesion who underwent ASA technique. Exclusion criteria were GBL >25%, multidirectional instability, preexisting osteoarthritis, and overhead sports activities. Visual analog scale (VAS) scale for pain, Rowe score, and American Shoulder and Elbow Surgeons (ASES) scores were used to assess results. Loss of shoulder external rotation was measured with the arm at the side (ER1 position) or 90° in abduction (ER2 position). Analysis of variance and Fisher tests were used for data evaluation. Significance was established at P ≤ .05.

RESULTS

One hundred ten patients (84 men and 26 women, mean age 27 years) were evaluated with a mean follow-up of 40.5 months (range: 24 to 65 months). In 98 patients, a Hill-Sachs lesion was observed and in 57 patients a capsular deficiency was present. Three patients (2.7%) had a traumatic redislocation. At final follow-up, the mean scores were as follows: VAS scale decreased from a mean of 3.5 to 0.5 (P = .015), Rowe score increased from 57.4 to 95.3 (P = .035), and ASES score increased from 66.5 to 96.5 (P = .021). The mean deficit of external rotation was 8° ± 2.5° in the ER1 position and 4° ± 1.5° in the ER2 position.

CONCLUSIONS

The ASA procedure has been shown to be effective in restoring joint stability in patients practicing sports, affected by chronic anterior shoulder instability associated with anterior GBL (<25%), capsular deficiency, and Hill-Sachs lesions, with mild restriction of external rotation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The "Purse-string" Technique for Shoulder Stabilization, Description of the Technique, Long term Results and Literature Review

BACKGROUND

Over the last 2 decades arthroscopic stabilization and Bankart repair has gained popularity due to the advances in materials and surgical techniques. Results of arthroscopic stabilization have been similar to open without the risks of it. The number of anchors used has been suggested to be very important in "spot-weld" arthroscopic stabilization however the "purse-string" technique (PST) can achieve similar results using only one anchor. We describe technique and long term results from using the PST and search the literature for other papers regarding PST.

METHODS

Between 2003 and 2013 a total of 193 patients were operated. Patients included those with anterior instability. Using PubMed relevant studies reporting results of PST were identified.

RESULTS

Mean follow up was 2 (range 0.5 to 3) years. 9 (4.7%) patients experienced recurrent instability. Almost all patients (97%) returned to their sporting and leisure activities and all professional athletes went back to the same sport. One more UK centre reported 6.1% recurrence in 114 patients at 4 years follow up. These results are similar to the published 11% recurrence of instability after "spot-weld" arthroscopic techniques at 11 years clinical follow-up.

CONCLUSION

This study indicates that PST is safe and effective alternative method for the treatment of anterior shoulder instability. In this technique with one anchor simultaneous repair of labrum, creation of an anterior bumper and capsular shift can be achieved. It has the advantage of being cheaper, faster yet efficient with good long term results and leaves space for revision anchors in case of recurrence.

Arthroscopic Bankart repair associated with subscapularis augmentation (ASA) versus open Latarjet to treat recurrent anterior shoulder instability with moderate glenoid bone loss: clinical comparison of two series

PURPOSE

The treatment of chronic anterior shoulder instability with glenoid bone loss is still debated. The purpose of this study is to compare short-term results of two techniques treating chronic shoulder instability with moderate glenoid bone loss: bone block according to open Latarjet-Patte procedure and arthroscopic Bankart repair in association with subscapularis augmentation.

METHODS

Ninety-one patients with moderate anterior glenoid bone loss underwent from 2011 to 2015. From these patients, two groups of 20 individuals each have been selected. The groups were homogeneous in terms of age, gender, dominance and glenoid bone loss. In group A, an open Latarjet procedure has been performed, and in group B, an arthroscopic Bankart repair associated with subscapularis augmentation has been performed. The mean follow-up in group A was 21 months (20-39 months), while in group B was 20 months (15-36 months). QuickDash score, Constant and Rowe shoulder scores, were used for evaluations of results.

RESULTS

The mean preoperative rate of QuickDash score was 3.6 for group A and 4.0 for group B; Rowe Score was 50.0 for group A and 50.0 for group B. Preoperative mean Constant score was 56.2 for Latarjet-Patte and 55.2 for Bankart plus ASA. Postoperative mean QuickDash score was in group A 1.8 and 1.7 in group B; Rowe Score was 89.8 and 91.6; Constant Score was 93.3 and 93.8. No complications related to surgery have been observed for both procedures. Not statistically significant difference was reported between the two groups (p > .05). Postoperatively, the mean deficit of external rotation in ER1 was -9° in group A and -8 in group B; In ER2, the mean deficit was -5° in both groups (p = .0942).

CONCLUSIONS

Arthroscopic subscapularis augmentation of Bankart repair is an effective procedure for the treatment of recurrent anterior shoulder instability with glenoid bone loss without any significant difference in comparison with the well-known open Latarjet procedure.

A Biomechanical Analysis of Anchor Placement for Bankart Repair: Effect of Portal Placement

During arthroscopic Bankart repair, penetration of suture anchors through the far cortex can compromise the initial biomechanical characteristics of anchor stability and repair integrity. This study compared the placement of suture anchors through a low anterior-inferior rotator interval portal (AI) vs a trans-subscapularis portal to evaluate the rate of anchor perforation as well as biomechanical strength. Ten matched pairs of cadaveric shoulders were randomized to an AI or a trans-subscapularis portal for placement of suture anchors at the 3 o'clock and 5:30 positions. The following measurements were obtained: (1) distance from the portal to the cephalic vein; (2) presence and length of anchor penetration through the inferior glenoid; and (3) ultimate failure strength of the anchors. The distance from the portal to the cephalic vein was significantly greater with the AI vs the trans-subscapularis portal across all specimens (29.9 vs 11.2 mm, P<.05). The rate of anchor penetration was significantly increased in the AI group vs the trans-subscapularis group at the 5:30 position (60% vs 10%, P=.014) but not at the 3 o'clock position (P=.33). Mean pullout strength of the anchors at the 5:30 position trended higher in the trans-subscapularis group, but the difference was not significant (132.8 vs 112.6 N, P=.18). The cephalic vein is closer to the trans-subscapularis portal than to the AI, but is at a safe distance. Both the rate and the degree of glenoid suture anchor penetration were lower with the trans-subscapularis portal compared with the AI at the 5:30 position. Placing anchors through the trans-subscapularis portal provides a safe alternative method, with improved positioning of the inferiormost anchor compared with the traditional AI.

A prospective cohort study investigating the effect of generalized joint hypermobility on outcomes after arthroscopic anterior shoulder stabilization

OBJECTIVES

Generalized joint laxity has been proposed as a significant risk factor for failure after arthroscopic anterior shoulder stabilization. The purpose of this study was to prospectively measure joint mobility in patients undergoing arthroscopic anterior shoulder stabilization and to determine whether hypermobility is a risk factor for worse outcomes compared with patients having normal joint mobility.

METHODS

Patients with anterior shoulder instability were prospectively enrolled. Generalized joint hypermobility was measured using the Beighton Hypermobility Score and the Rowe, UCLA, SANE, SST, and WOSI scores were administered and reported as patient outcomes preoperatively and following arthroscopic anterior shoulder stabilization at 6 weeks, 6 months, 12 months, and 24 months postoperatively. Patients were stratified into two groups based on their Beighton Hypermobility Score, with scores ≥ 4/9 indicative of joint hypermobility.

RESULTS

Sixteen patients with joint hypermobility (JH) and 18 non-hypermobile patients (NJH) were enrolled. At baseline, there were no significant differences in demographic characteristics or baseline patient-reported outcomes. Significantly more patients in the NJH group had SLAP tears (n = 10) compared to the JH group (n = 2) (p = .013). At all follow-up times, there were no significant differences between the NJH and JH groups with regard to patient-reported outcome scores (p > .05). In the JH group, 17% of patients reported recurrent instability at two years postoperatively compared to 25% of patients in the NJH group. There was no significant difference in failure rate (p = .67).

CONCLUSION

There was no significant difference in patient-reported outcomes or recurrent instability in patients with versus without joint hypermobility undergoing arthroscopic anterior shoulder stabilization.

Comparison of Time to Recurrence of Instability After Open and Arthroscopic Bankart Repair Techniques

Background:

The results of open and arthroscopic instability repairs have been shown to be equivalent in recent literature.

Purpose:

To compare the time to recurrence (TTR) of instability and disease-specific outcome measures in patients undergoing open and arthroscopic Bankart repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients with recurrent traumatic anterior shoulder instability and a Bankart lesion on diagnostic arthroscopy underwent either open Bankart repair (OB) or arthroscopic Bankart and suture capsulorrhaphy (ABSC) using suture anchors. There was a minimum follow-up of 24 months. The primary outcome measures included Western Ontario Shoulder Instability Index (WOSI) score and time to recurrence of instability (dislocation or subluxation). Rowe score, Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons (ASES) score, and Short Form–12 (SF-12) score were also compared.

Results:

A total of 82 shoulders in 80 patients (ABSC, n = 58; OB, n = 24) were evaluated at a mean of 39 months postoperatively. There were 4 clinical failures in the OB group (4 dislocations) and 7 clinical failures in the ABSC group (2 dislocations and 5 subluxations; P = .72 vs OB). The mean time to recurrence of postoperative instability was significantly shorter in the ABSC group (12.6 ± 2.7 months) compared with the OB group (34.2 ± 12 months; P = .04). The WOSI score in the OB group (265 ± 48.1) was better but not statistically significantly compared with the ABSC group (449.8 ± 63.8; P = .06).

Conclusion:

The time to recurrence of instability after open Bankart repair is significantly longer compared with arthroscopic Bankart repair.

Clinical Relevance:

Delayed time to recurrence after open Bankart repair suggests that the open technique may be more suited to withstand the high stress and demands of a heavy-duty profession (contact athletes and heavy manual labor).

History of surgical intervention of anterior shoulder instability

BACKGROUND

Anterior glenohumeral instability most commonly affects younger patients and has shown high recurrence rates with nonoperative management. The treatment of anterior glenohumeral instability has undergone significant evolution over the 20th and 21 centuries.

METHODS

This article presents a retrospective comprehensive review of the history of different operative techniques for shoulder stabilization.

RESULTS

Bankart first described an anatomic suture repair of the inferior glenohumeral ligament and anteroinferior labrum in 1923. Multiple surgeons have since described anatomic and nonanatomic repairs, and many of the early principles of shoulder stabilization have remained even as the techniques have changed. Some methods, such as the Magnusson-Stack procedure, Putti-Platt procedure, arthroscopic stapling, and transosseous suture fixation, have been almost completely abandoned. Other strategies, such as the Bankart repair, capsular shift, and remplissage, have persisted for decades and have been adapted for arthroscopic use.

DISCUSSION

The future of anterior shoulder stabilization will continue to evolve with even newer practices, such as the arthroscopic Latarjet transfer. Further research and clinical experience will dictate which future innovations are ultimately embraced.

Shoulder Conditions: Diagnosis and Treatment Guideline

The following guideline covers a wide array of shoulder conditions seen in the workers' compensation, as well as the nonworkers' compensation, population. The guideline is intended to help establish work relatedness and aid in making the diagnosis of shoulder injuries and degenerative conditions. It also provides a nonoperative and operative guideline for the treatment of several shoulder conditions, not limited to rotator cuff tears, subacromial impingement syndrome, acromioclavicular arthritis and dislocations, as well as glenohumeral arthritis.

Arthroscopic Bankart repair: Have we finally reached a gold standard?

Traditionally, surgical stabilization of the unstable shoulder has been performed through an open incision. Arthroscopic Bankart repair with suture anchors is now widely considered the treatment of choice for anterior shoulder instability in patients who have failed conservative management. Many different factors have now been elucidated for adequate treatment of glenohumeral instability. Because of technical advances in instability repair combined with an increased understanding of factors that lead to recurrent instability, the outcomes following arthroscopic Bankart repair have significantly improved and approach those of open techniques.

Clinical outcomes following revision anterior shoulder arthroscopic capsulolabral stabilization

INTRODUCTION

Traditionally surgeons have treated failed shoulder instability with open capsulolabral repair. Despite improved instrumentation, technique and familiarity in shoulder arthroscopy, few studies have reported the outcomes of arthroscopic revision shoulder instability repair. The purpose of this study was to assess clinical outcomes in patients following revision shoulder arthroscopic anterior capsulolabral stabilization.

MATERIALS AND METHODS

Sixty-two patients (63 shoulders) with failure of primary instability repairs were treated with revision arthroscopic anterior shoulder stabilization at a mean follow-up of 46.9 ± 16.8 months (range 18-78). Clinical outcomes were evaluated using validated patient-reported outcome questionnaires including the American Shoulder and Elbow Surgeons score, Simple Shoulder Test, visual analog pain scale and Western Ontario Shoulder Instability Index. In addition, patients were queried for recurrent instability events (subluxation or dislocation) or revision surgery.

RESULTS

At final follow-up, the mean postoperative Western Ontario Shoulder Instability normalized score was 80.1 ± 18.7 (range 15.0-100). There were clinically significant improvements in American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores and ten-point visual analog scale for pain (P < 0.001). Recurrent instability occurred in 12 shoulders (19.0 %), with number of prior surgeries and hyperlaxity found to be significant risk factor for failure (P < 0.001 and P = 0.04, respectively).

CONCLUSION

Revision arthroscopic anterior stabilization of the shoulder can result in satisfactory outcomes in appropriately selected patients who have failed previous capsulolabral repair. An increased number of prior surgeries and hyperlaxity are predictive of poor outcome.

STUDY DESIGN

Case series, LOE IV.

A Meta-Analysis of Arthroscopic versus Open Repair for Treatment of Bankart Lesions in the Shoulder

Background

The optimal treatment for Bankart lesion remains controversial. Therefore, we performed this meta-analysis to compare the clinical outcomes of patients managed with open Bankart repair versus arthroscopic Bankart repair.

Material/Methods

After systematic review of online databases, a total of 11 trials with 1022 subjects were included. The methodological quality of randomized controlled trials (RCTs) was assessed using the PEDro critical appraisal tool, and non-RCTs were evaluated by Newcastle-Ottawa (NO) quality assessment tool. Outcomes of shoulder stability, range of motion (ROM), functional scales, and surgical times were analyzed.

Results

Data synthesis showed significant differences between the two strategies, with regards to stability of the shoulder (P=0.008, RR=0.94, 95% CI: 0.89 to 0.98), and ROM (P<0.001, SMD=−0.47, 95% CI: −0.72 to −0.22).

Conclusions

Open Bankart repair produced a more stable shoulder but had a relatively poor shoulder motion, compared with arthroscopic Bankart repair, for the treatment of Bankart lesion.

Open Bankart Repair for the Treatment of Anterior Shoulder Instability without Substantial Osseous Glenoid Defects: Results After a Minimum Follow-up of Twenty Years

BACKGROUND

Neglected osseous glenoid defects are thought to be one of the reasons for the reported high rates of recurrent instability at long-term follow-up after Bankart repair. We hypothesized that open Bankart repair for the treatment of anterior glenohumeral instability in the absence of a substantial osseous glenoid defect would result in a lower long-term recurrence rate than has been reported in previous long-term studies.

METHODS

Forty-seven patients were treated with a primary modified open Bankart repair for recurrent anterior shoulder instability between 1989 and 1994. Double-contrast computed tomography scanning was used to exclude patients with a substantial osseous glenoid defect. Forty patients (85.1%) were available for subjective and objective follow-up at a minimum of twenty years (maximum, twenty-five years). Twenty-six patients (65%) underwent clinical examination as well as bilateral shoulder radiography, and fourteen (35%) completed a self-assessment questionnaire and were interviewed by telephone.

RESULTS

Seven patients (17.5%) had a recurrence of instability, and six of them had the instability occur after more than eight years without symptoms. The mean Western Ontario Shoulder Instability Index score (and standard deviation) was 256.7 ± 284.8 points; the mean Rowe score, 88.7 ± 12.0 points; and the mean Subjective Shoulder Value, 90.1% ± 10.5%.The mean range of motion of the affected shoulder was decreased by 4° of abduction (p = 0.009), two levels of internal rotation (p = 0.003), 5° of internal rotation in 90° of abduction (p = 0.005), 7° of external rotation in neutral position (p < 0.001), and 7° of external rotation in 90° of abduction (p = 0.004) compared with the contralateral side. The collective instability arthropathy (CIA) index was 0.92 for the affected side and 0.35 for the contralateral side.

CONCLUSIONS

Open Bankart repair provides good results twenty years after surgery in terms of subjective and objective outcome measurements. However, the long-term failure rate remains high despite the exclusion of substantial osseous glenoid defects. Recurrence of instability seems to be associated with an increased shoulder-specific activity level.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Combined Arthroscopic Bankart Repair and Coracoid Process Transfer to Anterior Glenoid for Shoulder Dislocation in Rugby Players: Evaluation Based on Ability to Perform Sport-Specific Movements Effectively

PURPOSE

To evaluate the outcomes of a combination of an arthroscopic Bankart repair and an open Bristow procedure in relation to the subjective quality of performance in movements that are typical in rugby.

METHODS

Forty shoulders in 38 players who underwent surgery for traumatic anterior instability of the shoulder were reviewed. In all cases, arthroscopic Bankart repair was followed by a Bristow procedure, with preservation of the repaired capsular ligaments, during the same operation. The mean age at the time of surgery was 21 years. Patients were asked to describe common rugby maneuvers (tackle, hand-off, jackal, and saving) preoperatively and postoperatively as "no problem," "insufficient," or "impossible."

RESULTS

There were no recurrent dislocations at a mean follow-up of 30.5 months. The mean Rowe score improved significantly from 65.0 (range, 55 to 75) to 97.5 (range, 95 to 100) (P < .001) after surgery. Preoperatively, regarding the tackling motion, none of the patients reported having no problem, whereas the ability was described as insufficient for 23 shoulders and impossible for 17 shoulders. Postoperatively, no problem with tackling was reported for 36 shoulders, whereas insufficiency was reported for 4. The results for the hand-off, jackal, and saving maneuvers were similar (P < .001). No patient rated any of the motions as impossible postoperatively.

CONCLUSIONS

This combined surgical procedure clearly is effective in preventing recurrent dislocation in rugby players; however, some players complained of insufficiency in the quality of their play when they were tackling or performing other rugby-specific movements.

LEVEL OF EVIDENCE

Level IV, case series.

Utility of the Instability Severity Index Score in Predicting Failure After Arthroscopic Anterior Stabilization of the Shoulder

BACKGROUND

The redislocation rate after arthroscopic stabilization for anterior glenohumeral instability is up to 30%. The Instability Severity Index Score (ISIS) was developed to preoperatively rationalize the risk of failure, but it has not yet been validated by an independent group.

PURPOSE

To assess the utility of the ISIS in predicting failure of arthroscopic anterior shoulder stabilization and to identify other preoperative factors for failure.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A case-control study was performed on 141 consecutive patients, comparing those who suffered failure of arthroscopic stabilization with those who had successful arthroscopic stabilization. The mean follow-up time was 47 months (range, 24-132 months). The ISIS was applied retrospectively, and an analysis was performed to establish independent risk factors for failure. A receiver operator coefficient curve was constructed to set a threshold ISIS for considering alternative surgery.

RESULTS

Of 141 patients, 19 (13.5%) suffered recurrent instability. The mean ISIS of the failed stabilization group was higher than that of the successful stabilization group (5.1 vs 1.7; P < .001). Independent risk factors for failure were Hill-Sachs lesion (P < .001), glenoid bone loss (P < .001), age <21 years at the time of surgery (P < .001), age at first dislocation (P = .01), competitive-level participation in sports (P < .001), and participation in contact or overhead sports (P = .03). The presence of glenoid bone loss carried the highest risk of failure (70%). There was a 70% risk of failure if the ISIS was ≥4, as opposed to a 4% risk of failure if the ISIS was <4.

CONCLUSION

This is the first completely independent study to confirm that the ISIS is a useful preoperative tool. It is recommended that surgeons consider alternative forms of stabilization if the ISIS is ≥4.

Effect of bone loss in anterior shoulder instability

Anterior shoulder instability with bone loss can be a difficult problem to treat. It usually involves a component of either glenoid deficiency or a Hill-Sachs lesion. Recent data shows that soft tissue procedures alone are typically not adequate to provide stability to the shoulder. As such, numerous surgical procedures have been described to directly address these bony deficits. For glenoid defects, coracoid transfer and iliac crest bone block procedures are popular and effective. For humeral head defects, both remplissage and osteochondral allografts have decreased the rates of recurrent instability. Our review provides an overview of current literature addressing these treatment options and others for addressing bone loss complicating anterior glenohumeral instability.

Anterior Glenoid Rim Fracture Following Use of Resorbable Devices for Glenohumeral Stabilization

BACKGROUND

Resorbable anchors are widely used in arthroscopic stabilization of the shoulder as a means of soft tissue fixation to bone. Their function is to ensure repair stability until they are replaced by host tissue. Complications include inflammatory soft tissue reactions, cyst formation, screw fragmentation in the joint, osteolytic reactions, and enhanced glenoid rim susceptibility to fracture.

PURPOSE

To evaluate resorption of biodegradable screws and determine whether they induce formation of areas with poor bone strength that may lead to glenoid rim fracture even with minor trauma.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study evaluated 12 patients with anterior shoulder instability who had undergone arthroscopic stabilization with the Bankart technique and various resorbable anchors and subsequently experienced redislocation. The maximum interval between arthroscopic stabilization and the new dislocation was 52 months (mean, 22.16 months; range, 12-52 months). The mean patient age was 31.6 years (range, 17-61 years). The persistence or resorption of anchor holes; the number, area, and volume of osteolytic lesions; and glenoid erosion/fracture were assessed using computed tomography scans taken after redislocation occurred.

RESULTS

Complete screw resorption was never documented. Osteolytic lesions were found at all sites (mean diameter, 5.64 mm; mean depth, 8.09 mm; mean area, 0.342 cm(2); mean volume, 0.345 cm(3)), and all exceeded anchor size. Anterior glenoid rim fracture was seen in 9 patients, even without high-energy traumas (75% of all recurrences).

CONCLUSION

Arthroscopic stabilization with resorbable devices is a highly reliable procedure that is, however, not devoid of complications. In all 12 patients, none of the different implanted anchors had degraded completely, even in patients with longer follow-up, and all induced formation of osteolytic areas. Such reaction may lead to anterior glenoid rim fracture according to the literature and as found in 75% of the study patients with local osteolysis (9/12). Reducing anchor number and/or size may reduce the risk of osteolytic areas and anterior glenoid rim fracture.

Effectiveness and safety of arthroscopic versus open Bankart repair for recurrent anterior shoulder dislocation: a meta-analysis of clinical trial data

PURPOSE

To evaluate the effectiveness and safety of arthroscopic and open Bankart repair for recurrent anterior shoulder dislocation using meta-analysis of data from clinical trials.

MATERIALS AND METHODS

Cochrane Register of Controlled Trials, PUBMED and EMBASE were used to search and identify clinical trials that evaluated arthroscopic and open Bankart repair for recurrent anterior shoulder dislocation. Methodological qualities of studies were assessed by Cochrane Collaboration tool for assessing risk of bias and Newcastle-Ottawa Scale. Publication bias was detected using Begg's test and Egger's test.

RESULTS

Sixteen trials involving 827 shoulders were included in the study. Based on Cochrane Collaboration tool for assessing risk of bias, three studies were rated as high quality and one study was rated as moderate quality among the randomized controlled trials. Another twelve case-control studies were rated as high quality based on Newcastle-Ottawa Scale. No significant publication bias was detected by Begg's test or Egger's test. Meta-analysis results indicated that arthroscopic repair has a significantly better recovery rate for external rotation at 90° of abduction, external rotation at side (P > 0.05) and forward flexion. However, arthroscopic repair had higher rates of recurrence and reoperation than open Bankart repair.

CONCLUSION

Meta-analysis of available randomized controlled trials and case-control studies demonstrated that arthroscopic repair and open Bankart repair were similar in safety. Arthroscopic repair resulted in better recovery of range of motion, but recurrence and reoperation rates were higher than open Bankart repair.

Structural and clinical integrity of the rotator cuff in athletes after arthroscopic Bankart repair using the three-portal technique

INTRODUCTION

Muscular recovery of structural integrity after arthroscopic Bankart repair using the para- and trans-musculotendinous three-portal technique has not been investigated.

MATERIALS AND METHODS

Twenty-seven athletes [mean age 26.9 years, (group 1; G1)] were prospectively and longitudinally monitored after arthroscopic Bankart repair using the three-portal technique by magnetic resonance imaging (MRI) and specific clinical muscular testing. The muscular integrity was assessed at the subscapularis (SSC) for the para-tendinous anteroinferior portal, the supraspinatus (SSP) for the trans-tendinous suprabicipital portal, and the infraspinatus (ISP) for the trans-tendinous posterior portal. Muscular atrophy was assessed by standardized ratios of transverse and vertical diameters for the SSC and ISP, as defined by cross-sectional area ratios for the SSP. Fatty infiltration was assessed by signal intensity analysis for the upper and lower SSC, SSP, and upper ISP as a ratio with the lower ISP. These parameters were analyzed for pre-operative (T0), 1-year (T1), and 2-year status (T2), and compared to 27 healthy volunteers [mean age 29.4 years, (group 2, G2)].

RESULTS

The structural integrity assessments were performed after 14.8 (T1) and 32.0 months (T2). The SSC analysis revealed no muscular impairments in the upper and lower portions between T0 and T2 or compared to G2. MRI analysis for SSP and ISP showed full muscular recovery without any changes between T0 and T2 or deficits compared to G2. The number of pre-operative dislocations had no influence on the muscular integrity. MR analysis detected signs of overuse syndrome in 15 % at T0, 41 % at T1, and 63 % at T2; 77, 22, and 26 % of patients at T0, T1, and T2, respectively, were symptomatic.

CONCLUSIONS

Arthroscopic Bankart repair using the three-portal technique prevents full muscular integrity for para-tendinous anteroinferior portals at the SSC, the trans-tendinous suprabicipital portal through the SSP, and the trans-tendinous portal through the ISP.

Approach to the treatment of primary anterior shoulder dislocation: A review

Glenohumeral joint dislocation is common among younger, active patients. Anterior dislocation is the most common direction of instability following a traumatic event. Due to a high rate of recurrence following primary traumatic anterior shoulder dislocation, an evidence-based approach is necessary to determine the best treatment regime for a patient presenting with this problem. A history, physical examination, and radiographic imaging can help guide treatment recommendations by determining the extent of soft tissue damage following dislocation. Controversies in the treatment of the first-time dislocator include the length and position of immobilization following dislocation, and the role of initial surgical stabilization. This article outlines the treatment options for the first-time glenohumeral dislocator, with an emphasis on the available evidence in the literature. Where applicable, the criteria known as the Strength of Recommendation Taxonomy were used to summarize the strength of evidence available for recommendations.

Do arthroscopic and open stabilization techniques restore equivalent stability to the shoulder in the setting of anterior glenohumeral instability? a systematic review of overlapping meta-analyses

PURPOSE

Shoulder instability frequently recurs in young patients without operative treatment. Both open and arthroscopic approaches to shoulder stabilization with labral repair and capsulorrhaphy have been described and are routinely used. Multiple trials have been conducted to compare these approaches, with multiple meta-analyses performed to synthesize these trials; however, the results remain controversial. The purpose of this study was to critically evaluate the current meta-analyses to identify the current state of the art.

METHODS

In this study we evaluate available scientific support for the ability of both arthroscopic and open soft-tissue stabilization techniques to restore stability of the shoulder by performing a systematic review of the literature for previous meta-analyses. Data were extracted for rates of recurrence and patient outcomes. Study quality was measured with the Oxman-Guyatt and QUOROM (Quality of Reporting of Meta-analyses) systems. The Jadad algorithm was applied independently by 4 authors to determine which meta-analysis provided the highest level of available evidence.

RESULTS

After application of the inclusion and exclusion criteria, 8 meta-analyses were included. Both studies published prior to 2007 concluded that open stabilization provided lower recurrence rates than arthroscopic stabilization, the 3 studies published in 2007 are discordant, and all 3 studies published after 2008 concluded that open and arthroscopic stabilization provided equivalent results. Two meta-analyses had low Oxman-Guyatt scores (<3) signifying major flaws. Four authors independently selected the same meta-analysis as providing the highest quality of evidence using the Jadad algorithm, and this meta-analysis found no difference in recurrence rates between open and arthroscopic stabilization.

CONCLUSIONS

This systematic review of overlapping meta-analyses comparing arthroscopic and open shoulder stabilization suggests that according to current best available evidence, there are no significant differences in failure rates.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Traumatic anterior instability of the pediatric shoulder: a comparison of arthroscopic and open bankart repairs

BACKGROUND

Arthroscopic and open Bankart repairs have proven efficacy in adults with recurrent anterior shoulder instability. Although studies have included children in their analysis, none have previously compared functional outcomes or redislocation rates between these 2 methodologies for anteroinferior glenoid labrum repair in this young population. We hypothesize that open and arthroscopic Bankart repair in children will have similar functional outcomes and redislocation rates, but differing results from adults treated in a similar manner.

METHODS

A retrospective chart review was performed on all Bankart repairs performed between 2006 and 2010 at a tertiary care children's hospital. A shift in treatment modalities occurred in 2008 creating 2 cohorts, open and arthroscopic. Brachial plexus injury, congenital soft-tissue disorder, or incomplete charts were excluded. Demographics, age at surgery, follow-up length, and sport were recorded. Telephone interviews were then performed obtaining the most current QuickDASH (Disability Arm, Shoulder, or Hand), WOSI (Western Ontario Shoulder Instability Index), SF-12 (Short Form 12), SANE (Single Assessment Numeric Evaluation), and verbal pain scores; as well as, inquiring about recurrent dislocation and further surgery.

RESULTS

Ninety-nine children (16.9±1.5 y) were included (28 open, 71 arthroscopic). There were no differences in preoperative demographics. Fifty-one patients completed the questionnaires (11 open, 40 arthroscopic). No significant differences in the outcomes scores were seen between the 2 groups. Of the 99 patients, 21 (21%) had redislocation or secondary surgery; there was no significant difference in failure rate between groups (4 open, 17 arthroscopic). A plotted survival curve demonstrated that the adolescent shoulder undergoing Bankart repair for recurrent traumatic anterior instability has a 2-year survival of 86% and a 5-year survival of only 49%, regardless of technique.

CONCLUSIONS

In adolescents, there is no significant difference in functional outcomes or redislocation rates between open and arthroscopic Bankart repair, yet both demonstrate a very high risk of failure in this young, athletic population which contrasts the results in the historic adult population.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

An analysis of technical aspects of the arthroscopic Bankart procedure as performed in the United States

PURPOSE

The purpose of this study was to investigate the intersurgeon variation in technical aspects of performing an arthroscopic Bankart repair.

METHODS

A unique approach with experienced equipment representatives from 3 different arthroscopic companies was used. Experienced representatives were identified by DePuy Mitek, Smith & Nephew, and Arthrex and filled out questionnaires on how their surgeons performed arthroscopic Bankart procedures. This was performed in a blinded fashion with no knowledge of the identities of the specific surgeons or representatives by us. A video on different aspects of the procedure was observed by each representative before filling out the questionnaire to help standardize responses. Data were collected using REDCap (Research Electronic Data Capture). Data were analyzed as an infrequent observation with 0% to 30% of representatives reporting the observation; sometimes, 31% to 70% reporting the observation; and often, greater than 70% of representatives reporting.

RESULTS

Seventy-six percent of representatives had 6 or more years of arthroscopic experience. Forty-three percent of representatives reported that their surgeons use 3 portals for the procedure often. Forty-four percent reported that viewing was performed exclusively from the posterior portal while the surgeon was performing the repair. Seventy-three percent reported that the Hill-Sachs lesion was observed often, and 61% reported that the posterior labrum was evaluated often before the repair. Only 25% of representatives reported that the Bankart lesion was extensively released and mobilized often. Thirty-three percent reported 3 anchors as being used often. Seventy-five percent reported biocomposite anchors as being used often. Single-loaded anchors were reported as being used often by 47%. Eighty-one percent reported that sutures were placed in a simple fashion. Eighty-three percent reported the use of any posterior sutures or anchors for additional plication as infrequent.

CONCLUSIONS

There is significant variation in performance of the arthroscopic Bankart repair in the United States. Areas of concern include completeness of the diagnostic examination, the adequacy of capsulolabral mobilization, variation in the use of accessory portals, and inconsistent use of additional capsular or labral plication or fixation.

Outcomes of arthroscopic anterior shoulder instability in the beach chair versus lateral decubitus position: a systematic review and meta-regression analysis

PURPOSE

This study aimed to systematically review the clinical outcomes and recurrence rates after arthroscopic anterior shoulder stabilization in the beach chair (BC) and lateral decubitus (LD) positions.

METHODS

The authors performed a systematic review of multiple medical databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All English-language literature from 1990 to 2013 reporting clinical outcomes after arthroscopic anterior shoulder stabilization with suture anchors or tacks with a minimum 2-year follow-up period were reviewed by 2 independent reviewers. Data on recurrent instability rate, return to activity/sport, range of motion, and subjective outcome measures were collected. Study methodological quality was evaluated with the Modified Coleman Methodology Score (MCMS) and the Quality Appraisal Tool (QAT). To quantify the structured review of observational data, meta-analytic statistical methods were used.

RESULTS

Sixty-four studies (38 BC position, 26 LD position) met inclusion criteria. A total of 3,668 shoulders were included, with 2,211 of patients in the BC position (average age, 26.7 ± 3.8 years; 84.5% male sex) and 1,457 patients in the LD position (average age, 26.0 ± 3.0 years; 82.7% male sex). The average follow-up was 49.8 ± 29.5 months in the BC group compared with 38.7 ± 23.3 months in the LD group. Average overall recurrent instability rates were 14.65 ± 8.4% in the BC group (range, 0% to 38%) compared with 8.5% ± 7.1% in the LD group (range, 0% to 30%; P = .002). The average postoperative loss in external rotation motion (in abduction) was reported in 19 studies in the BC group and in13 studies in the LD group, with an average loss of 2.4° ± 1.0° and 3.6° ± 2.6° in each group, respectively (P > .05).

CONCLUSIONS

Excellent clinical outcomes with low recurrence rates can be obtained after arthroscopic anterior shoulder stabilization in either the BC or the LD position; however, lower recurrence rates are noted in the LD position. Additional long-term randomized clinical trials comparing these positions are needed to better understand the potential advantages and disadvantages of each position.

LEVEL OF EVIDENCE

Level IV, systematic review of studies with Level I through Level IV evidence.

The arthroscopic treatment of shoulder instability: bioabsorbable and standard metallic anchors produce equivalent clinical results

PURPOSE

To investigate whether there are any differences in clinical outcomes and complications between absorbable and nonabsorbable suture anchors in the treatment of shoulder instability.

METHODS

We performed a comprehensive search of Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, and the Cochrane Central Registry of Controlled Trials, from inception of the databases, using various combinations of keywords. Only studies focusing on clinical outcomes of patients who underwent arthroscopic shoulder stabilization with suture anchors were selected. Two authors (R.P. and L.D.B.) then evaluated the methodologic quality of each article using the Coleman Methodology Score.

RESULTS

Ten articles were included. Four were prospective randomized studies, 2 were prospective cohort studies, and 4 were case series. The mean modified Coleman Methodology Score was 76.2.

CONCLUSIONS

Given the overall good results reported after arthroscopic stabilization of the shoulder using different suture anchors, it is not possible to draw a definite and solid suggestion on which class of device is better advised for routine use. Thus the decision to use one of the anchor systems available may mostly depend on its cost-effectiveness, which should be the focus of future comprehensive research.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Is the American Society of Shoulder and Elbow Therapists' rehabilitation guideline better than standard care when applied to Bankart-operated patients? A controlled study

OBJECTIVE

To determine whether there is a difference in shoulder-related physical function and quality of life between postoperative rehabilitation patients receiving standard care and those receiving care according to the American Society of Shoulder and Elbow Therapists' rehabilitation guideline for arthroscopic anterior capsulolabral repair of the shoulder.

DESIGN

Descriptive studies with comparison between a retrospective and a prospective cohort.

SETTING

Municipal outpatient rehabilitation centre.

PATIENTS

A total of 96 arthroscopic Bankart-operated patients.

INTERVENTIONS

A total of 52 patients received standard care; 44 patients underwent rehabilitation according to the American Society of Shoulder and Elbow Therapists' rehabilitation guideline.

MAIN MEASUREMENTS

Primary outcome variable was Western Ontario Shoulder Instability Index. Secondary outcome measures were Patient-Specific Functional Scale, shoulder range of motion, return to work, return to sports, and costs.

RESULTS

There was no significant difference in adjusted mean change scores between the standard care group and the guideline group in the primary outcome variable (Western Ontario Shoulder Instability Index total = 574.85 vs. 644.48) or the secondary outcomes (Patient-Specific Functional Scale = 4.6 vs. 5.0; range of motion in forward flexion = 46.49° vs. 49.58°; external rotation in adduction = 28.58° vs. 34.18°; external rotation in abduction = 51.29° vs. 47.55°; weeks until return to work = 5.2 vs. 6.9; weeks until return to sports =13.9 vs. 13.1; costs = number of visits; 18.5 vs. 15.9).

CONCLUSIONS

There were no significant between-group differences in shoulder-related physical function and quality of life between the standard care group and the guideline group, following Bankart operations.

Movement control in patients with shoulder instability: a comparison between patients after open surgery and nonoperated patients

BACKGROUND

Open surgery to correct shoulder instability is deemed to facilitate recovery of static and dynamic motor functions. Postoperative assessments focus primarily on static outcomes (e.g., repositioning accuracy). We introduce kinematic measures of arm smoothness to assess shoulder patients after open surgery and compare them with nonoperated patients. Performance among both groups of patients was hypothesized to differ. Postsurgery patients were expected to match healthy controls.

METHODS

All participants performed pointing movements with the affected/dominant arm fully extended at fast, preferred, and slow speeds (36 trials per subject). Kinematic data were collected (100 Hz, 3 seconds), and mixed-design analyses of variance (group, speed) were performed with movement time, movement amplitude, acceleration time, and model-observed similarities as dependent variables. Nonparametric tests were performed for number of velocity peaks.

RESULTS

Nonoperated and postsurgery patients showed similarities at preferred and faster movement speeds but not at slower speed. Postsurgery patients were closer to maximally smoothed motion and differed from healthy controls mainly during slow arm movements (closer to maximal smoothness, larger movement amplitude, shorter movement time, and lower number of peaks; i.e., less movement fragmentation).

CONCLUSIONS

Arm kinematic analyses suggest that open surgery stabilizes the shoulder but does not necessarily restore normal movement quality. Patients with recurrent anterior shoulder instability (RASI) seem to implement a "safe" but nonadaptive mode of action whereby preplanned stereotypical movements may be executed without depending on feedback. Rehabilitation of RASI patients should focus on restoring feedback-based movement control. Clinical assessment of RASI patients should include higher order kinematic descriptors.

Arthroscopic versus open shoulder stabilization: current practice patterns in the United States

PURPOSE

The purpose of this study was to investigate current trends in arthroscopic and open shoulder stabilization in the United States.

METHODS

Patients who underwent arthroscopic shoulder stabilization (Current Procedural Terminology code 29806) or open stabilization (Current Procedural Terminology codes 23455 [open Bankart repair], 23460 [anterior bone block], and 23462 [coracoid transfer]) were identified using a national database of insurance billing records during the years 2004 through 2009. Demographic data were recorded for each patient.

RESULTS

From 2004 through 2009, there were 23,096 cases of shoulder stabilization, of which 84% (19,337) were arthroscopic and 16% (3,759) were open procedures. There were 17,241 male patients (75%) and 5,855 female patients (25%). The incidence of arthroscopic shoulder stabilization nearly doubled during the period studied, increasing from 11.8 cases for every 10,000 patients in 2004 to 22.9 cases for every 10,000 patients in 2009. The percentage of arthroscopic stabilizations increased from 71% of stabilization procedures in 2004 to 89% in 2009, whereas the percentage of open stabilizations decreased from 29% in 2004 to 11% in 2009 (P < .0001). Among open procedures, a significant decline in the incidence of open Bankart repair was observed, from 4.5 cases for every 10,000 patients in 2004 to 2.2 cases for every 10,000 patients in 2009 (P < .0001), whereas the performance of open coracoid transfer increased from 0.17 cases per 10,000 patients in 2004 to 0.40 cases per 10,000 patients in 2009 (P < .0001). For both arthroscopic and open stabilization, the group aged 10 to 19 years had the highest rate of surgery (29%), followed by the group aged 20 to 29 years (25%).

CONCLUSIONS

The current data indicate that arthroscopic stabilization is performed in nearly 90% of shoulder stabilization surgeries and nearly doubled in incidence from 2004 to 2009 in the United States. Additional research is needed to further investigate the long-term clinical outcomes of this practice pattern.

LEVEL OF EVIDENCE

Level IV, retrospective database review.

A randomized clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability: two-year follow-up with disease-specific quality-of-life outcomes

BACKGROUND

The literature comparing open and arthroscopic repair for glenohumeral instability is conflicting. We performed a prospective, expertise-based, randomized clinical trial to compare open shoulder stabilization with arthroscopic shoulder stabilization by measuring quality-of-life outcomes and recurrence rates at two years among patients treated for traumatic anterior shoulder instability.

METHODS

Computer-generated, variable-block-size, concealed randomization allocated 196 patients to either the open-repair group (n = 98) or the arthroscopic-repair group (n = 98). An expertise-based randomization design was employed to avoid a differential bias in terms of physician experience. Outcomes were measured at baseline, at three and six months postoperatively, and at one and two years postoperatively with use of the Western Ontario Shoulder Instability Index (WOSI) and the American Shoulder and Elbow Surgeons (ASES) functional outcome scale. Recurrent instability was also analyzed.

RESULTS

There were no significant differences in outcome scores at baseline. At two years, seventy-nine patients in the open group and eighty-three patients in the arthroscopic group were available for follow-up. There was no significant difference in mean WOSI scores between the groups; the mean WOSI score (and standard deviation) for the open group was 85.2 ± 20.4 (95% confidence interval [CI] = 80.5 to 89.8), and for the arthroscopic group, 81.9 ± 19.8 (95% CI = 77.4 to 86.4); p = 0.31. There was also no significant difference in mean ASES scores: 91.4 ± 12.7 (95% CI = 88.5 to 94.4) for the open group and 88.2 ± 15.9 (95% CI = 84.6 to 91.8) for the arthroscopic group; p = 0.17. Recurrence rates at two years were significantly different: 11% in the open group and 23% in the arthroscopic group (p = 0.05). Recurrent instability was more likely in patients with a preoperative Hill-Sachs lesion and in male patients who were twenty-five years old and younger. There was no significant difference in shoulder motion between the groups at two years.

CONCLUSIONS

There was no difference between open and arthroscopic repair in terms of patient quality of life. Open repair resulted in a significantly lower risk of recurrence. Secondary outcome data from this trial suggest that open surgical repair may be recommended to reduce the risk of recurrent instability in younger male patients with a Hill-Sachs lesion.

Recurrent instability after revision anterior shoulder stabilization surgery

PURPOSE

The purpose of this study was to perform a systematic review of the literature to compare outcomes of revision anterior stabilization surgeries based on technique. This study also sought to compare the impact of bone defects on outcomes.

METHODS

A systematic review of the electronic databases PubMed, Cochrane Central Register of Controlled Trials, and Scopus was performed in July 2012 and March 2013. Of 345 articles identified in the search, 17 studies with Level I to IV Evidence satisfied the inclusion criteria and were analyzed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Recurrent instability was defined as redislocation, resubluxation, or a positive apprehensive test after revision surgery. Procedures were categorized as arthroscopic Bankart repair, open Bankart repair, Bristow-Latarjet procedure, and other open procedures.

RESULTS

In total, 388 shoulders were studied. Male patients comprised 74.1% of patients, 66.7% of cases involved the dominant shoulder, the mean age was 28.2 years, and the mean follow-up period was 44.2 months. The surgical procedures classified as "other open procedures" had the highest rate of recurrent instability (42.7%), followed by arthroscopic Bankart repair (14.7%), the Bristow-Latarjet procedure (14.3%), and open Bankart repair (5.5%). Inconsistent reporting of bone defects precluded drawing significant conclusions.

CONCLUSIONS

A number of different procedures are used to address recurrent instability after a primary operation for anterior shoulder instability has failed. There is significant variability in the rate of recurrent instability after revision anterior shoulder stabilization surgery.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to IV studies.

Return to Play After Open Bankart Repair: A Systematic Review

Background:

Results of open Bankart repair have been well reported. However, less information is available outlining the timetable for return to play (RTP) in athletes after this procedure.

Purpose:

To review the current literature regarding (1) the timetable recommended for athletes to RTP after an open Bankart repair and (2) the objective criteria on which the decision to allow an athlete to RTP is based.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A comprehensive literature search was conducted of all relevant English-language articles using the electronic databases OVID and PubMed between the years 1947 and 2012 to identify open Bankart repair. Two reviewers screened articles for eligibility based on the following criteria: (1) an open Bankart repair, (2) a minimum follow-up of at least 8 months, (3) any report that described the procedure in athletes, and (4) any report that described the time for an athlete to RTP. All relevant data were collected and analyzed with regard to number of patients; mean follow-up; Rowe, Constant, and American Shoulder and Elbow (ASES) scores; redislocation rate; and return-to-sport timing.

Results:

In all, 559 relevant citations were identified, of which 29 articles met the inclusion criteria. The mean follow-up was 51.7 months (range, 8-162 months), and the mean age was 25.9 years (range, 21-31 years). The average Rowe score for all studies was 86.9 (range, 63-90). The average redislocation rate was 5.3%. Twenty-six of 29 studies cited a specific timetable for unrestricted RTP, with an average of 23.2 weeks (range, 12-36 weeks). Only 38% of authors reported sport-specific criteria for return to competition, with the majority allowing return to noncontact sports at 12 to 16 weeks, and the resumption of throwing/contact sports by 24 weeks. Three reports described specific functional parameters for RTP.

Conclusion:

The current review summarized return-to-play guidelines for athletic competition after open Bankart repair. These data may provide general guidelines to aid surgeons when determining the appropriate timetable to allow an athlete to return to unrestricted competition.

Outcomes after bankart repair in a military population: predictors for surgical revision and long-term disability

PURPOSE

To quantify the rate of surgical failure after anterior shoulder stabilization procedures, as well as to identify demographic and surgical risk factors associated with poor outcomes.

METHODS

All Army patients undergoing arthroscopic or open Bankart repair for shoulder instability were isolated from the Military Health System Management Analysis and Reporting Tool between 2003 and 2010. Demographic variables (age, gender) and surgical variables (treatment facility volume, admission status, surgical technique) were extracted. Rates of surgical failure, defined as subsequent revision surgery or medical discharge with persistent shoulder complaints, were recorded from the electronic medical record and US Army Physical Disability Agency database. Risk factor analysis was performed with univariate t tests, χ(2) tests, and a multivariable logistic regression model with failure as the outcome.

RESULTS

A total of 3,854 patients underwent Bankart repair during the study period, with most procedures having been performed arthroscopically (n = 3,230, 84%) and on an outpatient basis (n = 3,255, 84%). Patients were predominately men (n = 3,531, 92%), and the mean age was 28.0 years (SD, 7.5 years). A total of 193 patients (5.0%) underwent revision stabilization whereas 339 patients (8.8%) were medically discharged with complaints of shoulder instability, for a total combined failure rate of 13.8% (n = 532). Univariate analyses showed no significant effect for gender; however, younger age, higher facility volume, open repair, and inpatient status were significant factors associated with subsequent surgical failure. Multivariable analyses confirmed that young age (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.91 to 0.96; P < .001), open repair (OR, 0.52; 95% CI, 0.36 to 0.75; P = .001), and inpatient status (OR, 0.58; 95% CI, 0.40 to 0.84; P = .004) were independently associated with failure by revision surgery.

CONCLUSIONS

Young age remains a significant risk factor for surgical failure after Bankart repair. Patients who underwent arthroscopic Bankart repair had a significantly lower surgical failure rate (4.5%) than patients who underwent open anterior stabilization (7.7%). Despite advances in surgical technique, 1 in 20 military service members required revision surgery after failed primary stabilization in this study.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic Bankart repair augmented by plication of the inferior glenohumeral ligament via horizontal mattress suturing for traumatic shoulder instability

INTRODUCTION

This study aimed to evaluate the two-year clinical outcomes of arthroscopic Bankart repair augmented by plication of the inferior glenohumeral ligament (IGHL) via horizontal mattress suturing.

METHODS

This study was a retrospective analysis of 76 arthroscopic Bankart repairs by a single surgeon from 2004 to 2008. Bioabsorbable suture anchors were used, with anchors placed at the 5:30, 4 and 3 o'clock positions of the right shoulder (correspondingly at the 6:30, 8 and 9 o'clock positions for the left shoulder). The lower most anchor was tied via horizontal mattress suture with plication of the IGHL, while the remaining two anchors were tied using simple sutures. The patients were postoperatively assessed, clinically and using the University of California Los Angeles (UCLA) shoulder rating scale.

RESULTS

The mean age of the patients at the time of presentation was 24.09 ± 7.98 years, and the mean duration of follow-up was 28.7 months. The postoperative recurrence rate of dislocation was 7.89% (six shoulders), of which five shoulders required revision surgeries. Excluding the revision cases, clinical assessment of the strength of the supraspinatus and the range of motion of the operated shoulders at two years post operation were either maintained or full in all patients. Analysis of the UCLA results showed pre- and postoperative mean scores of 25.94 ± 3.43 and 33.77 ± 3.07, respectively (p < 0.05).

CONCLUSION

Arthroscopic Bankart repair augmented by plication of the IGHL and anchored via horizontal mattress suturing is a safe and reliable treatment for shoulder instability, with good clinical outcomes and low recurrence rates.

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.

Revision arthroscopic Bankart repair

PURPOSE

Failed anterior shoulder stabilization procedures have traditionally been treated with open procedures. Recent advances in arthroscopic techniques have allowed for certain failed stabilization procedures to be treated by arthroscopic surgery. The aim of this systematic review was to determine the outcomes of revision arthroscopic Bankart repair.

METHODS

We searched Medline, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) for articles on revision arthroscopic Bankart repairs. Key words included shoulder dislocation, anterior shoulder instability, revision surgery, and arthroscopic Bankart repair. Two reviewers selected studies for inclusion, assessed methodologic quality, and extracted data.

RESULTS

We included 16 studies comprising 349 patients. All studies were retrospective (1 Level II study and 15 Level IV studies). The mean incidence of recurrent instability after revision arthroscopic Bankart repair was 12.7%, and the mean follow-up period was 35.4 months. The most common cause for failure of the primary surgeries was a traumatic injury (62.1%), and 85.1% of patients returned to playing sports. The reasons for failure of revision cases included glenohumeral bone loss, hyperlaxity, and return to contact sports.

CONCLUSIONS

With proper patient selection, the outcomes of revision arthroscopic Bankart repair appear similar to those of revision open Bankart repair. Prospective, randomized clinical trials are required to confirm these findings.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II and Level IV studies.