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

No Clear Difference in Clinical Outcomes Between Knotted and Knotless Arthroscopic Bankart Repair: A Systematic Review

PURPOSE

To analyze whether the arthroscopic Bankart repair using a knotless suture anchor has a better functional outcome than the conventional knot-tying Bankart repair.

METHODS

A comprehensive literature search was done in the PubMed, Scopus, Embase, and Cochrane databases in May 2023. Studies comparing the clinical outcome of Bankart repair using knotless and knot-tying techniques were included in the study. In vitro, animal, and Level IV and V studies were excluded. The risk of bias in randomized controlled trials was calculated according to the RoB 2 tool, and for nonrandomized studies, Methodological Index for Non-Randomized Studies criteria were used. Statistical analysis was done using RevMan software.

RESULTS

A total of 9 studies, including 2 randomized controlled trials and 7 nonrandomized comparative studies involving 720 patients, were included in the systematic review. The ROWE score ranged from 81.7 to 94.3 in the knot-tying group and 86 to 96.3 in the knotless group. Visual Analog Scale scores at the final follow-up ranged from 0.1 to 1.7 in the knot-tying group and 0.7 to 2.5 in the knotless group. The rate of redislocation, subluxation, and revision surgery in the knot-tying group ranged from 0% to 14.7%, 16.7% to 29.7%, and 1.6% to 17.6%, respectively, whereas that in the knotless group ranged from 2.4% to 23.8%, 7.4% to 22.2%, and 2.4% to 19%, respectively. The mean external rotation was 54° to 65° in the knot-tying group and 61° to 99° in the knotless group. The mean forward-flexion was 164 to 172 in the knot-tying group and 165 to 174 in the knotless group. Our subjective synthesis does not reveal any difference in the outcome between the 2 groups.

CONCLUSIONS

The available literature does not demonstrate a clear difference in functional outcomes, residual pain, and rate of complications as redislocation, subluxation, and revision surgery between Bankart repairs performed with knotted and knotless anchors.

LEVEL OF EVIDENCE

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

Controversies in surgical management of anterior shoulder instability. State of the Art

Arthroscopic Bankart repair (ABR) has been accepted as a standard procedure for anterior shoulder instability with a minimum or no glenoid bone loss and an on-track Hill-Sachs lesion if present. However, several controversies exist in the surgical treatment of anterior shoulder instability. This article will discuss some of these controversies in, "simple," dislocations (without bone loss) as well as, "complex," (with critical bone loss). Determining which patients will benefit from an arthroscopic procedure depends on multiple factors including age, activity level, adequate determination of bone loss, performed with feasible and reliable imaging techniques. In the absence of concomitant significant bony and soft tissue pathology, ABR alone can provide satisfactory clinical results on a long-term basis. Controversies, including whether to remove cartilage from the edge of the glenoid, knotted versus knotless anchors, and routine rotator interval closure, still exist. In cases with significant bone loss, several bone restoring procedures have been described, such as, the Latarjet procedure, iliac crest bone graft, arthroscopic anatomic glenoid reconstruction with a frozen distal tibial allograft, and fresh distal tibial allograft reconstruction. This article will address these controversies and provide guidance based on available published data.

All-Suture Anchor vs. Knotless Suture Anchor for the Treatment of Anterior Shoulder Instability-A Prospective Cohort Study

All-suture or soft-anchors (SA) represent a new generation of suture anchor technology with a completely suture-based system. This study's objective was to assess Juggerknot® SA, for arthroscopic Bankart repair in recurrent shoulder instability (RSI), and to compare it to a commonly performed knotless anchor (KA) technique (Pushlock®). In a prospective cohort study, 30 consecutive patients scheduled for reconstruction of the capsulolabral complex without substantial glenoid bone loss were included and operated on using the SA technique. A historical control group was operated on using the KA technique for the same indication. Clinical examinations were performed preoperatively and 12 and 24 months postoperatively. RSI and WOSI at 24 months were the co-primary endpoints, evaluated with logistic and linear regression. A total of 5 out of 30 (16.7%) patients suffered from RSI in the SA group, one out of 31 (3.2%) in the KA group (adjusted odds ratio = 10.12, 95% CI: 0.89-115.35), and 13.3% in the SA group and 3.2% in the KAgroup had a revision. The median WOSI in the SA group was lower than in the KA group (81% vs. 95%) (adjusted regression coefficient = 10.12, 95% CI: 0.89-115.35). Arthroscopic capsulolabral repair for RSI using either the SA or KA technique led to satisfying clinical outcomes. However, there is a tendency for higher RSI and lower WOSI following the SA technique.

Jeor JD, Trasolini NA, Waterman BR. Batter's Shoulder: All-Knotless Posterior Labral Repair With Retensionable Anchors for Treatment of Batter's Shoulder

Batter's Shoulder is a unique injury that may be associated with recurrent microtrauma followed by acute subluxation of the humeral head on the posterior glenoid edge, leading to posterior labral tears. Early identification of this injury is critical, as it may be treated with conservative nonsurgical treatments prior to labral tear onset. If conservative treatment fails and pain persists, surgical options include arthroscopic fixation to reapproximate the posterior labrum to the glenoid and restore capsular tension. Previous studies have shown the benefit of using knotless suture anchors in arthroscopic shoulder fixation. This technical note demonstrates that Batter's Shoulder is a unique injury associated with posterior labral tears of the shoulder and provides a contemporary method of arthroscopic fixation of a posterior labral tear using retensionable knotless all-suture anchors.

Shoulder Stabilization Technique Using the Medial Glenohumeral Ligament in Patients With the Buford Complex

The Buford complex is an anatomic variation defined as the association of a cordlike middle glenohumeral ligament (MGHL) and an absent anterosuperior labrum. It can be challenging to properly identify on preoperative imaging and remains mostly an arthroscopic finding. It may, however, lead to problematic situations when encountered during an arthroscopic soft-tissue stabilization procedure, as the treatment of choice in such cases is a bone block. Moreover, reattaching the MGHL to the anterior border of the glenoid rim has traditionally not been recommended because it theoretically leads to severe restriction in external rotation. This technical note describes arthroscopic stabilization for anterior traumatic glenohumeral instability associated with the Buford complex. The cordlike MGHL is used to reconstruct a neo-labrum, associated with an anteroinferior glenohumeral ligament plication. Glenohumeral stabilization using the cordlike MGHL of the Buford complex may be an efficient alternative to a bone block procedure.

Clinical Results of Knot-tying Versus Knotless Suture Anchors in Arthroscopic Anteroinferior Labral Repair

Background Arthroscopic repair of glenohumeral instability is becoming an increasingly common procedure. These repairs can be undertaken using knot-tying and knotless suture anchors; there is currently no clear consensus in the literature about what type of repair is most cost-effective and provides superior outcomes. The purpose of this study is to examine postoperative outcomes of patients undergoing arthroscopic anteroinferior labral repair (AALR) with either knot-tying or knotless anchors. Methods A single institution retrospective observational cohort study of 122 patients undergoing AALR from January 2014 to June 2021 was conducted. Univariate statistics were used to assess differences in demographics, operative characteristics, and postoperative outcomes between repair types; multivariate analysis was used to evaluate risk factors for recurrent instability and reoperation. Results Patients undergoing AALR with knotless anchors had a shorter case duration than those with knot-tying anchors (112.64 vs. 89.86 minutes, p<0.001). There were no significant differences between groups in the size of labral tear, presence of a glenoid bone defect, or Hill-Sachs lesion. After controlling for age, BMI, sex, glenoid bone defect, number of preoperative dislocations, and fixation type, only age (OR=0.896, p=0.010) and female sex (OR=5.341, p=0.008) were independent risk factors for recurrent instability and no factors were independent predictors of reoperation. Conclusion Patients undergoing AALR experienced similar rates of reoperation and recurrent instability regardless of whether a knot-tying or knotless repair was performed. The use of knotless suture anchors may improve cost-effectiveness due to decreased surgical time without diminishing postoperative outcomes.

Fixation devices for anterior shoulder instability

PURPOSE

Over the past 40 years, advances in the development of anchors and sutures have contributed to the improvement in surgical outcomes for treatment of shoulder instability. Important choices in surgery when treating instability include the use of knotless versus knotted suture anchors, and bony versus soft tissue reconstruction techniques.

METHODS

A literature review was conducted to evaluate the history of instability of the shoulder and the results of specific fixation techniques including bony and soft tissue reconstructions as well as knotted and knotless suture anchors.

RESULTS

As knotless suture anchors have continued to grow in popularity since their development in 2001, many studies have compared this newer technique to that of the standard knotted suture anchors. In general, these studies have demonstrated no difference in patient-reported outcome measures between the two options. Additionally, the choice of bony versus soft tissue reconstructions is patient specific as it depends on the specific pathology or combination of injuries.

CONCLUSION

In each surgery performed for shoulder instability, it is vitally important that we try to restore normal anatomy. The normal anatomy is best established by knotted mattress sutures. However, loop laxity and tear through by the sutures in the capsule can eliminate this restoration, increasing risk of failure. Knotless anchors may allow better soft tissue fixation of the labrum and capsule to the glenoid, but without complete restoration of normal anatomy.

The Longitude-Latitude-Loop Used for Complex Bankart Lesion Repair: An All-Arthroscopic Technique

The most frequent operation for anterior shoulder instability is the arthroscopic Bankart repair, which has a positive outcome and a low rate of complications. A variety of restoration procedures have been reported to reconstruct labral height and reproduce a dynamic concavity-compression reaction. The longitude-latitude loop is a knotless high-strength suture method that simultaneously tightens the joint capsule in the warp and weft direction and resists tearing. The suture method is safe and reproducible. This study aimed to present a longitude-latitude loop suture for joint capsule labral complex repair during Bankart arthroscopy surgery.

No Clinical or Radiographic Difference Seen in Arthroscopic Bankart Repair With Knotted Versus Knotless Suture Anchors: A Randomized Controlled Trial at Short-Term Follow-Up

PURPOSE

The objective of this study was to compare the clinical and radiographic results of patients undergoing arthroscopic repair of labral lesions using knotted and knotless anchors.

METHODS

Sixty-four patients with anterior labral lesions (bone defects of the glenoid up to 13.5% or up to 20% if the instability severity index score was less than 4) and without other shoulder pathologies were randomly assigned to 2 groups, with 32 patients in each group. Clinical outcomes were assessed 6, 12, and 24 months after surgery by the Rowe score, Western Ontario shoulder instability index (WOSI), single assessment numeric evaluation (SANE), visual analog scale for pain (VASp), range of motion, and rate of postoperative recurrence. Postoperative magnetic resonance imaging (MRI) was performed, and the anterior and inferior labrum glenoid height indexes and anterior and inferior labral slopes were measured. The primary endpoint was the Rowe score at 24 months postoperatively.

RESULTS

Fifty-one patients, 24 in the knotted group and 27 in the knotless group, completed 24 months of follow-up. At 24 months, the Rowe scores were 81.7 ± 19.9 points and 85.9 ± 14 points, respectively (P = .623); the WOSI scores were 509.2 ± 480.1 points and 555.9 ± 393.6 points, respectively (P = .533); the SANE scores were 90.7 ± 18.7 points and 89.2 ± 14.8 points, respectively (P = .427); and the VASp scores were 1.7 ± 2.5 points and 2.5 ± 2.7 points, respectively (P = .275). There was no significant difference in range of motion, postoperative recurrence, or MRI parameters between the groups. All subjects (100%) in both groups exceeded the minimal clinically important difference of 9.7 for the Rowe score (P > .999).

CONCLUSION

Repair of Bankart's lesion through the use of knotted and knotless suture anchors yielded similar clinical and radiographic results on analysis at 24 months after operation.

LEVEL OF EVIDENCE

Level I. Randomized controlled clinical trial.

Single Knotless Suture Anchor Repair of Anterior Talofibular Ligament Following Distal Fibula Nonunion Excision

Anterior talofibular ligament (ATFL) tear is the most common ankle ligament injury. This can lead to recurrent ankle instability, which is detrimental to ankle function and the patient's quality of life. Currently, several techniques have shown successful outcomes for ATFL repair. In this technical note, we describe an open ATFL repair using a single knotless suture anchor at the distal fibula location. This approach is rapid, equipment-efficient, and reproducible, while promising excellent results and high patient satisfaction by restoring ATFL anatomy.

Arthroscopic Labral Repair Using Knotless Suture Anchors in the Setting of a 270° Labral Tear of the Shoulder

Extensive glenoid labral tears, whether the result of repetitive instability or first-time dislocation, compromise the mechanical stability of the glenohumeral joint due to disruption of the anterior, inferior, posterior, and/or superior portions of the labrum. These lesions often result in recurrent multiplanar instability and pain that is nonresponsive to conservative management and difficult to diagnose due to variability in clinical presentation and advanced imaging findings. Arthroscopic repair techniques to address symptomatic shoulder instability have showed positive patient-reported outcomes, low failure rates, and high return-to-sport rates. The evolution of knotless suture anchors offers a fixation method that has proven to be functionally equivalent to knotted suture anchors while avoiding the risks of knotted anchors (knot loosening, knot migration, articular abrasion) and allowing easier placement and decreased operative time. The purpose of this technique is to describe our preferred method to treat a 270° labral tear through arthroscopic knotless anchor repair and demonstrate the expanded application of this technique for extensive glenoid labral pathology.

Knot-Tying versus Knotless Suture Anchors for Arthroscopic Bankart Repair: A Comparative Study

PURPOSE

This study aimed to compare the results of using knotless and knot-tying suture anchors in arthroscopic Bankart repair.

MATERIALS AND METHODS

The patients who underwent arthroscopic Bankart repair between 2011 and 2017 using knot-tying and knotless suture anchors were retrospectively reviewed. We collected demographic data, clinical scores (pain visual analogue scale), functional visual analogue scale, American Shoulder and Elbow Society scores, and Rowe score), and range of motion (ROM). Re-dislocation and subjective anterior apprehension test rates between the two techniques were also analyzed.

RESULTS

Of the 154 patients who underwent arthroscopic Bankart repair, 115 patients (knot-tying group: n=61 and knotless group: n=54) were included in this study. Of the 115 patients, 102 were male and 13 were female. The mean patient age was 27 years (range: 17-60), and the mean follow-up period was 43 months (range: 24-99). There were no significant differences in the final clinical scores and ROM between the two groups. Re-dislocation was observed in 6 (9.8%) and 4 (7.3%) patients in the knot-tying and knotless groups, respectively. Apprehension was observed in 11 (18.0%) and 12 (22.2%) patients in the knot-tying and knotless groups, respectively. There were no significant differences between the two groups in regards to re-dislocation and anterior apprehension.

CONCLUSION

Re-dislocation rates and clinical scores were similar with the use of knotless and knot-tying suture anchors in arthroscopic Bankart repair after a minimal 2 year follow-up.

Excellent Functional Outcomes and Low Complication Rates Following Knotless Arthroscopic Bankart Repair: A Systematic Review of Clinical and Biomechanical Studies

PURPOSE

To provide a comprehensive review of the current clinical and biomechanical evidence for the use of knotless suture anchors during arthroscopic Bankart repair.

METHODS

A comprehensive search of 5 electronic databases from inception to July 2020 was performed for clinical and biomechanical studies in English evaluating outcomes following arthroscopic Bankart repair using knotless suture anchors. Two independent reviewers assessed articles for inclusion. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORs) criteria. Clinical outcomes of interest and key findings from biomechanical studies were summarized.

RESULTS

Ten clinical studies (430 knotless repairs), including 4 cohort studies directly comparing knotless (N = 117) to knot-tying repairs (N = 192), were deemed eligible. Four biomechanical studies were also identified. Heterogeneity and the lack of randomized studies precluded data pooling and quantitative meta-analysis. Rates of redislocation ranged from 2.2% to 14.7% and 1.5% to 23.8% for knot-tying and knotless repair, respectively. Both knot-tying and knotless repair demonstrated excellent postoperative functional outcome, as assessed by visual analog scale, Constant-Murley, Rowe, and QuickDASH scores, with 80% to 94% of patients returning to sports participation. Biomechanical studies showed similar stiffness and load to failure between knot-tying and knotless repairs, with the most common mode of failure being retear at the suture-soft tissue interface.

CONCLUSIONS

Current level II to IV clinical and biomechanical evidence supports knotless arthroscopic Bankart repair as an effective procedure with excellent functional outcomes and low rates of complication and reoperation.

LEVEL OF EVIDENCE

Level IV, systematic review of level II to IV studies.