Arthroscopic Bankart repair with the Suretac device. Part II: Experimental observations

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.

History of shoulder instability surgery

PURPOSE

The surgical management of shoulder instability is an expanding and increasingly complex area of study within orthopaedics. This article describes the history and evolution of shoulder instability surgery, examining the development of its key principles, the currently accepted concepts and available surgical interventions.

METHODS

A comprehensive review of the available literature was performed using PubMed. The reference lists of reviewed articles were also scrutinised to ensure relevant information was included.

RESULTS

The various types of shoulder instability including anterior, posterior and multidirectional instability are discussed, focussing on the history of surgical management of these topics, the current concepts and the results of available surgical interventions.

CONCLUSIONS

The last century has seen important advancements in the understanding and treatment of shoulder instability. The transition from open to arthroscopic surgery has allowed the discovery of previously unrecognised pathologic entities and facilitated techniques to treat these. Nevertheless, open surgery still produces comparable results in the treatment of many instability-related conditions and is often required in complex or revision cases, particularly in the presence of bone loss. More high-quality research is required to better understand and characterise this spectrum of conditions so that successful evidence-based management algorithms can be developed.

LEVEL OF EVIDENCE

IV.

The American Society of Shoulder and Elbow Therapists' consensus rehabilitation guideline for arthroscopic anterior capsulolabral repair of the shoulder

This manuscript describes the consensus rehabilitation guideline developed by the American Society of Shoulder and Elbow Therapists. The purpose of this guideline is to facilitate clinical decision making during the rehabilitation of patients following arthroscopic anterior capsulolabral repair of the shoulder. This guideline is centered on the principle of the gradual application of stress to the healing capsulolabral repair through appropriate integration of range of motion, strengthening, and shoulder girdle stabilization exercises during rehabilitation and daily activities. Components of this guideline include a 0- to 4-week period of absolute immobilization, a staged recovery of full range of motion over a 3-month period, a strengthening progression beginning at postoperative week 6, and a functional progression for return to athletic or demanding work activities between postoperative months 4 and 6. This document represents the first consensus rehabilitation guideline developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients following arthroscopic anterior capsulolabral repair of the shoulder.

Bioabsorbable anchors in glenohumeral shoulder surgery

The use of implants to provide glenohumeral soft tissue fixation has changed dramatically over the past few decades, from point tack fixation to metallic suture anchors to bioabsorbable suture anchors. Bioabsorbable suture anchors have largely replaced metallic anchors because of concerns of implant loosening, migration, and chondral injury. Although the safety and efficacy of bioabsorbable anchors has been well documented, there are numerous reports regarding the early failure related to implant bioabsorbable implant breakage or premature degradation. Patients with anchor-related complications generally present with pain and/or stiffness, and the surgeon should have a high index of suspicion if a patient does not progress as expected. Glenohumeral synovitis, glenoid osteolysis, loose bodies, and chondral injury are some of the notable complications that have been reported. Careful attention to proper anchor insertion techniques can limit the potential for complications. Newer materials, such as polyetheretherketone and other composites, have recently been introduced. These materials may address concerns of biocompatibility and material strength, but additional rigorous in vitro and in vivo trials need to be conducted before their use becomes widespread.

Magnetic resonance imaging appearance of a repaired capsulolabral complex after arthroscopic bankart repair

BACKGROUND

Revision Bankart operations frequently show capsulolabral buttress loss and recurrent soft tissue Bankart lesion. Capsulolabral augmentation is designed to increase glenohumeral stability by 2 separate mechanisms: deepening the glenoid concavity and reducing capsular laxity. This is accomplished by shifting the capsule to buttress the glenoid labrum.

HYPOTHESIS

A retained capsulolabral buttress may show loss of height and slope at a certain period after surgery, regardless of stability. Thus, the authors wanted to confirm the importance of an intraoperative establishment of capsulolabral buttress in terms of stability.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Arthroscopically repaired Bankart lesions in 21 consecutive shoulders that showed no frank dislocation were evaluated using axial and oblique coronal T2-weighted magnetic resonance imaging at 3 timepoints (preoperative period, average postoperative week 6 and a nearly full range of motion recovery, and postoperative month 6 with a return to daily activity). The authors measured 2 parameters (height and slope) on axial (mainly capsulolabral containment) and oblique coronal images (mainly inferior glenohumeral ligament) at the anteroinferior portion of the glenoid (5 mm above the most inferior anchor). In addition, they compared the above-mentioned parameters at postoperative month 6 by magnetic resonance imaging in 21 controls and in 21 patients whose instability recurred after surgery (not included in the prospective study).

RESULTS

There was a significant increase between the preoperative period and postoperative week 6 in all 4 parameters (P < .0001). There was also a significant increase between the preoperative period and postoperative month 6 in all 4 parameters (P < .0001). However, no statistically significant difference was observed between postoperative week 6 and postoperative month 6 in all 4 parameters (P > .1). Furthermore, significant differences were observed between normal controls and patients with recurrent instability (P < .001) and between the authors' cases and patients with recurrent instability not in the study (P < .001). However, no difference was observed between their cases and normal shoulders (P > .1).

CONCLUSION

After suture anchor Bankart repair, initial capsulolabral buttress property was maintained at 6 months postoperatively. Furthermore, the buttress was more prominent in stable and normal shoulders than in recurrent instability shoulders. Therefore, the authors believe that the establishment of a capsulolabral buttress is meaningful during Bankart repair.

A biomechanical study of bankart lesion fixation - biodegradable ArthroRivet tack vs. suture repair

Bioabsorbable fixation is commonly used in soft tissue procedures performed in the shoulder. ArthroRivettrade mark tacks (referred to as rivets here), made from a copolymer of 82% poly-L-lactic acid and 18% polyglycolic acid, were developed for the Bankart procedure. Although a previous in vivo study demonstrated favorable comparison of the fixation strength and absorption characteristics of this device with that of polyglyconate bioabsorbable tacks, there have been no published biomechanical studies of this rivet in the shoulder. Fourteen shoulders were harvested from fresh-frozen cadavers of average age 74 years (46-89). Biomechanical testing was performed by measuring the energy, or work, required to anteriorly displace the humeral head 6 mm from the glenoid. Each shoulder was tested intact, vented, and before and after repair of a simulated Bankart lesion at 0, 45, and 90 degrees of abduction with and without maximal external rotation. Overall, the average work required ranged from 54.7 N-mm to 178.27 N-mm. Although the biomechanical performance of the rivet, based on resistance to anterior displacement of the humeral head, was indistinguishable from that of the suture repair, the statistical power of the test was low due to the large variance in the cadaver specimens. The results, in general, correlated well with those of previously published studies, suggesting the suitability of the bioabsorbable rivet for use in Bankart repair.

Arthroscopic Bankart repair using Knotless or BioKnotless suture anchors: 2- to 7-year results

PURPOSE

This study was performed to evaluate the results of arthroscopic Bankart repair, by use of Knotless or BioKnotless suture anchors (DePuy Mitek, Raynham, MA), for traumatic anterior shoulder instability.

METHODS

We performed a retrospective evaluation of 73 consecutive patients with traumatic anterior instability of the shoulder treated with arthroscopic Bankart repair by use of metallic Knotless or BioKnotless suture anchors. No additional capsular plication, thermal modification, or interval closure was performed in any patient. The senior author performed all procedures. Independent examiners performed physical examinations. Self-assessment questionnaire evaluations were completed, and preoperative and postoperative American Shoulder and Elbow Surgeons and Rowe scores are reported.

RESULTS

Results at a minimum of 2 years' follow-up (range, 2 to 7 years) are reported for 72 patients (57 male and 15 female patients) available for follow-up evaluation. One patient was lost to follow-up. Of the patients, 5 (6.9%) had post-repair instability (3 dislocations and 2 subluxations). The mean postoperative loss of external rotation, at 90 degrees of abduction, was 1 degrees . All patients who had postoperative instability were aged 22 years or younger. The post-repair instability rate in this age group was 13.5% (5/37). No failures occurred in patients aged over 22 years. Of the post-repair dislocations, 3 (7.5%) were in patients involved in contact or collision sports. All 5 failures occurred early, within 2 years of the index surgery. Revision arthroscopic repairs via Knotless or BioKnotless suture anchors were performed in 3 of 4 patients, and a Latarjet procedure was also performed in the fourth patient. The fifth patient refused further intervention. All of the revision shoulders remained stable at the latest follow-up, 3 of which had at least 2 years of follow-up.

CONCLUSIONS

Arthroscopic Bankart repair via Knotless or BioKnotless suture anchors showed a recurrence rate of 6.9%. Using Knotless or BioKnotless suture anchors provides satisfactory results with a low recurrence rate, minimal loss of motion, and reliable functional return, even in contact and collision athletes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Long-term results of arthroscopic Bankart repair with a bioabsorbable tack

BACKGROUND

Short-term to midterm data are available on arthroscopic shoulder stabilization using bioabsorbable tacks or suture anchors. It remains unknown whether these techniques can equal the success of open Bankart repair in the long term.

PURPOSE

To assess the long-term outcome of arthroscopic Bankart repair using bioabsorbable tacks in patients with traumatic anterior shoulder instability with a minimum follow-up of 7 years.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Treatment outcomes were determined prospectively according to the Rowe score and retrospectively according to the Constant and American Shoulder and Elbow Surgeons scores. Included in this study were 18 consecutive patients with a mean age of 26.8 years (range, 16-62 years) who underwent arthroscopic Bankart repair using bioabsorbable tacks for traumatic anterior shoulder instability. The study group consisted of 14 male and 4 female patients. The mean follow-up was 8.7 years (range, 7.0-9.8 years).

RESULTS

One patient had recurrent dislocations requiring further surgery, for an overall failure rate of 5.6%. An additional patient had 1 traumatic subluxation episode within the first postoperative year that did not recur. According to the Rowe score, which increased to 90.3 (17.8) from 32.8 (8.3) points preoperatively, 15 patients (83.3%) achieved a good or excellent result. The mean Constant score was 91.3 (SD, 6.9) points, and the mean American Shoulder and Elbow Surgeons score was 92.1 (SD, 6.9) points postoperatively. A return to the preinjury level of sports competition was reported by 64% of patients. No signs of synovitis occurred in any patient postoperatively.

CONCLUSION

Arthroscopic Bankart repair for the treatment of recurrent traumatic anterior shoulder instability repair using bioabsorbable tacks offers reliable results with respect to failure rate, range of motion, and shoulder function during a minimum follow-up of 7.0 years. In contrast to previous reports on arthroscopic Bankart repair, results did not deteriorate during follow-up.

Arthroscopic stabilization of superior labral (SLAP) tears with biodegradable tack: outcomes to 2 years

PURPOSE

This prospective study aimed to document the pain and functional outcomes, over time, of patients whose SLAP lesions had been repaired with biodegradable tacks.

METHODS

Superior labral tears were identified in 24 patients from a cohort of 500 patients who had shoulder problems sufficiently disabling to warrant arthroscopic evaluation and management. These labral tears were arthroscopically repaired with 1 to 3 biodegradable tacks (mean, 1.6). Before surgery, all patients completed a questionnaire regarding their shoulder pain and function and were given a systematic clinical examination. To observe their postoperative outcomes over time, the same assessments were made at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, and 2 years after surgery.

RESULTS

After labral reattachment, decreases were noted in the patients' mean shoulder pain scores at rest (64% at 3 months), at night (76% at 3 months), and with activity (73% at 6 months). The most significant reductions in mean scores occurred between 6 and 12 weeks (P < .001). Patient-perceived weakness, instability, and stiffness scores also improved from week 6. The ranking of the patients' "overall problem" reduced from an average ranking of "severe" to "mild" by the third preoperative month (P < .001) and was still at this level by the time of their 2-year follow-up appointment. Activity levels for 22 of 24 patients returned to their preinjury levels by 6 months after surgery.

CONCLUSIONS

Arthroscopically delivered biodegradable tacks effectively managed superior labral tears and, on average, resulted in a near-complete improvement of pain and recovery of function by 3 months. These good outcomes did not improve further or deteriorate at the 2-year follow-up appointment.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Suture anchors and tacks for shoulder surgery, part II: the prevention and treatment of complications

The use of suture anchors and tacks around the shoulder requires a thorough knowledge of the proper use of the devices and how to insert them. Although typically not technically demanding, suture anchors and tacks can present unique and frustrating challenges to the patient and the surgeon. These challenges can occur whether the procedure is performed via an open or arthroscopic approach, but knowledge of the potential challenges may optimize the surgical result and prevent complications. Complications can be categorized as technique-related or device-related issues (mechanical or biologic failure). Technique-related complications include problems with the delivery systems, anchor malpositioning, and suture management issues, such as knots not sliding. Device-related complications include implant fracture, migration secondary to poor fixation, synovitis from implant degradation, and osteolysis. This review describes the prevention of these and other complications, addresses the indications or need for intervention, and suggests potential solutions when intervention is indicated.

Suture anchors and tacks for shoulder surgery, part 1: biology and biomechanics

The development and successful clinical application of suture anchors and tacks have revolutionized the surgeon's ability to secure soft tissues to bone via open or arthroscopic surgical techniques. When used carefully and with proper technique, these devices provide viable options for the repair and reconstruction of many intra-articular and extra-articular abnormalities in the shoulder, including rotator cuff tears, shoulder instability, and biceps lesions that require labrum repair or biceps tendon tenodesis. Like many technologies, however, the successful application of these devices requires an understanding of the biology and biomechanics that affect their use in the shoulder as well as knowledge of the factors that can affect subsequent clinical outcomes, including complications.

[Open Bankart shoulder stabilization using bioabsorbable staples. Technique and results]

In the supply of anterior unidirectional instability the open Bankart repair still represents the standard procedure. In a retrospective study 48 patients with an open repair were supplied with bioabsorbable staples and the result with 42 patients (88%) was postoperative clinically examined following 18-48 months. The middle number of dislocations of the affected shoulder was 8.8. After surgery the average Rowe Score amounted to 96.1 points. Reluxations arose with two patients. The middle external rotation of the affected side was reduced in comparison to the opposite side by 9.7 degrees. With the open supply of the unidirectional instability by absorbable staples (Suretac) an easy procedure of the open operation according to Bankart is available. Reproducible results occurred in our patients. Thus the advantages of arthroscopical operation technology with those of the open execution of capsular shift are combined applicable, providing both patient and operating surgeon a high security at a low rate of reluxation.

Arthroscopic stabilization of anterior shoulder instability: a review of the literature

The treatment of anterior glenohumeral instability has been a topic of debate in the recent literature. Current surgical management of shoulder instability has included a variety of open and arthroscopic procedures. Open techniques for anterior reconstruction have been quite successful in preventing recurrent dislocations and continue to be the gold standard of care. In an attempt to address some of the disadvantages associated with open procedures, arthroscopic stabilization procedures have been developed. Arthroscopic capsuloligamentous repair presumably has clear advantages including better cosmesis, decreased perioperative morbidity, and a possible decrease in the loss of external rotation. Advances in arthroscopic instrumentation and improved arthroscopic techniques have increased the popularity of arthroscopic stabilization. The art of diagnosing the anatomic pathology associated with instability and proper patient selection continues to evolve. Most previous reports of arthroscopic stabilization have included small numbers of patients, variable patient pathology, and a variety of surgical techniques, making comparisons between stabilization procedures difficult. Arthroscopy can be valuable in both the confirmation of the degree and severity of the instability and to correct the pathoanatomy responsible for the instability.

Arthroscopic rotator cuff repair

The arthroscopic operation for repair of full-thickness rotator cuff tears is successful and has the advantages of glenohumeral joint inspection, treatment of intraarticular lesions, smaller incisions, no deltoid detachment, less soft tissue dissection, less pain, and more rapid rehabilitation. However, these advantages must be balanced against the technical difficulty of the method, which limits its application to surgeons skilled in open and arthroscopic shoulder operations.

A knotless suture anchor. Design, function, and biomechanical testing

The development of a unique Knotless suture anchor for soft tissue repair to bone is described. This device allows for soft tissue repair to bone using a suture anchor without the need for knot tying. This provides a particular advantage for arthroscopic repairs, where knot tying can be difficult. The Knotless suture anchor has a short loop of suture secured to the tail end of the anchor. A channel located at the tip of the anchor functions to capture the loop of suture after it has been passed through the soft tissue. The soft tissue is tensioned as the anchor is inserted into bone to the appropriate depth. Biomechanical testing demonstrated increased suture strength in the Knotless suture anchor compared with standard suture anchors. This is because of the doubled-suture configuration that is created with the Knotless suture anchor loop. To the author's knowledge, this paper describes the first knotless suture anchor. A secure, low-profile repair can be created without knot tying.

Arthroscopic shoulder instability surgery. Complications

Complications associated with arthroscopic shoulder stabilization are relatively common. Excluding recurrence, complications are rarely disabling. Current statistics undoubtedly underestimate the true incidence of complications. Many complications, including neurovascular injuries and articular damage, are preventable and can be minimized through familiarity with anatomy, proper surgical technique and instrumentation, and clinical experience. Nevertheless, despite these efforts, a few complications, including recurrent instability, persist. Despite careful patient selection and attention to labral pathology and capsular laxity, arthroscopic repairs continue to have success rates lower than those achieved through open means. While cautiously proceeding toward a more complete understanding of the instability continuum, surgeons must maintain a high index of suspicion for new techniques that purport to "solve" the problem of arthroscopic shoulder stabilization, lest the history of enthusiastic but ultimately unsubstantiated claims is repeated. Outcomes must withstand the rigors of scientific scrutiny and the test of time. Without this cautious vigilance, the appeal of today's solutions becomes the fodder of tomorrow's articles about the complications of arthroscopic shoulder stabilization.

Bioabsorbable suture anchor (co-polymer 85/15 D,L lactide/glycolide) implanted in bone: correlation of physical/mechanical properties, magnetic resonance imaging, and histological response

A novel bioabsorbable suture anchor has been introduced for shoulder rotator cuff surgical repair made of the co-polymer 85/15 D,L lactide/glycolide. Previous clinical reports on the use of this material in anterior cruciate ligament reconstruction have described intraosseous edema at various time intervals following implantation. The purpose of this study was to analyze the implant's loss of physical properties and to correlate magnetic resonance imaging (MRI) finding with gross and histological observations at various time intervals after intraosseous implantation in the experimental animal. Six drill holes were made in the tibias of 11 dogs. The spherical implant was placed in 5 of the drill holes and the sixth was preserved as a sham control. The dogs were killed at 3, 4, 6, 9, 12, and 26 weeks for gross and microscopic inspection. Correlative MRIs were taken from the 4-, 12-, and 26-week specimens. Gross inspection showed that the overlying soft tissue healed to bone in 3 weeks. The implants were surrounded by new bone by 6 weeks. The implants maintained gross physical integrity for 6 to 12 weeks. Histologically, there was minimal inflammatory response to the degrading implant. The implant site had been completely replaced by bone at 12 weeks. Correlative MRI showed edema adjacent to the implant sites, but there was no correlative inflammation or cyst formation through the time necessary for complete absorption of the implant. Correlative MRI identified and differentiated the image of the intact and degrading implant.

Open and arthroscopic techniques for the treatment of traumatic anterior shoulder instability in Australian rules football players

Australian Rules football (ARF) is a potentially violent, overhead, body-contact sport. We reviewed 56 shoulders in patients who sustained their initial traumatic anterior subluxation or dislocation during ARF and who underwent reconstructive surgery for traumatic anterior instability, whether by arthroscopic or by open techniques. Patients were followed up for a mean of 29.4 months after operation, and clinical evaluation was performed with the Rowe grading system. Three types of surgical procedures were performed: arthroscopic suture repair, arthroscopic Bankart repair with an absorbable polyglyconate tack, and open capsular shift with repair of the Bankart lesion. Shoulders treated with arthroscopic suture repair had a 70% rate of recurrent subluxation or dislocation on return to ARF Dislocations treated arthroscopically with the biodegradable tack had a 38% rate of recurrence of instability; three fourths of the recurrences were after minimal to moderate trauma. Shoulders treated with an open capsular shift and Bankart procedure had a 30% rate of recurrent instability, with half of the recurrences caused by violent trauma. In the open group there were no failures in patients who did not return to ARF. We suggest that arthroscopic repair in shoulders with anterior instability and recurrent dislocation does not adequately address the plastic deformation of the anterior capsule that may occur after repeated episodes of dislocation. We advocate open shoulder procedures in ARF athletes to address all areas of the capsulolabral pathologic condition and to provide the most secure repair possible with minimal chance of recurrence.

Early arthroscopic treatment of primary traumatic anterior shoulder dislocation. A follow-up study

This study evaluates the results of early arthroscopic Bankart repair in patients with primary traumatic anterior dislocation of the shoulder. The patients' age range was 17-34 years. Arthroscopic Bankart repair was performed within 12 days after the dislocation. First follow-up was at 18 months. According to Rowe's score, 11 patients (73%) were excellent, 3 (20%) were good and 1 (7%) was poor. The median external rotation deficit was 4 degrees in the adducted position. At a second follow-up at 34 months, two patients had redislocated. Both of these patients had severe generalized joint laxity. Another patient reported frequent subluxations. We conclude that in young patients with primary anterior traumatic shoulder dislocation, early arthroscopic Bankart repair implies a low recurrence rate and restores shoulder function to normal. Generalized joint laxity could indicate an increased risk for recurrent dislocation.

Percutaneous tensioning of the glenohumeral ligaments during arthroscopic bankart repair

Tensioning of the inferior glenohumeral ligament complex (IGLC) before arthroscopic repair is a critical step in restoring stability. This article describes a simple surgical technique to tension the IGLC percutaneously before arthroscopic fixation. This technique eliminates the need for grasping instruments and a second anterior portal.