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

The Continuous Fragility Index of Statistically Significant Findings in Randomized Controlled Trials That Compare Interventions for Anterior Shoulder Instability

BACKGROUND

Evidence-based care relies on robust research. The fragility index (FI) is used to assess the robustness of statistically significant findings in randomized controlled trials (RCTs). While the traditional FI is limited to dichotomous outcomes, a novel tool, the continuous fragility index (CFI), allows for the assessment of the robustness of continuous outcomes.

PURPOSE

To calculate the CFI of statistically significant continuous outcomes in RCTs evaluating interventions for managing anterior shoulder instability (ASI).

STUDY DESIGN

Meta-analysis; Level of evidence, 2.

METHODS

A search was conducted across the MEDLINE, Embase, and CENTRAL databases for RCTs assessing management strategies for ASI from inception to October 6, 2022. Studies that reported a statistically significant difference between study groups in ≥1 continuous outcome were included. The CFI was calculated and applied to all available RCTs reporting interventions for ASI. Multivariable linear regression was performed between the CFI and various study characteristics as predictors.

RESULTS

There were 27 RCTs, with a total of 1846 shoulders, included. The median sample size was 61 shoulders (IQR, 43). The median CFI across 27 RCTs was 8.2 (IQR, 17.2; 95% CI, 3.6-15.4). The median CFI was 7.9 (IQR, 21; 95% CI, 1-22) for 11 studies comparing surgical methods, 22.6 (IQR, 16; 95% CI, 8.2-30.4) for 6 studies comparing nonsurgical reduction interventions, 2.8 for 3 studies comparing immobilization methods, and 2.4 for 3 studies comparing surgical versus nonsurgical interventions. Significantly, 22 of 57 included outcomes (38.6%) from studies with completed follow-up data had a loss to follow-up exceeding their CFI. Multivariable regression demonstrated that there was a statistically significant positive correlation between a trial's sample size and the CFI of its outcomes (r = 0.23 [95% CI, 0.13-0.33]; P < .001).

CONCLUSION

More than a third of continuous outcomes in ASI trials had a CFI less than the reported loss to follow-up. This carries the significant risk of reversing trial findings and should be considered when evaluating available RCT data. We recommend including the FI, CFI, and loss to follow-up in the abstracts of future RCTs.

The History and Evolution of the Open Labral Repair with Capsular Shift for Shoulder Instability

PURPOSE OF REVIEW

The purpose of this review is to describe the evolution of the open labral repair with capsular shift, including the current role of this procedure in the treatment of shoulder instability.

RECENT FINDINGS

Currently, a subset of patients - high-level collision/contact sport athletes, patients with significant inferior or multi-directional instability, and individuals with failed arthroscopic Bankart repair without bone loss - may experience benefit from undergoing open Bankart repair with capsular shift. Surgeons performing open stabilization can benefit from instrumentation and anchors developed to assist with arthroscopic techniques. Understanding the history and evolution behind the procedure not only allows the surgeon to appreciate principles behind an arthroscopic approach, but also permits the utilization of an open approach when required by patient pathology and risk factors.

Arthroscopic Management of Anterior Shoulder Instability: A Study of Functional Outcome and Analysis

Background The remarkable range of motion of the shoulder comes at the cost of increased instability, especially anterior instability. Arthroscopic Bankart repair with or without remplissage, which is a minimally invasive surgery, is the preferred treatment for recurrent anterior instability. This study investigated the effectiveness of Bankart repair, with or without remplissage, in restoring function, preventing redislocation, and improving patient satisfaction. Methods A prospective observational study examined 40 patients (19-50 years old) with recurrent anterior instability and MRI-confirmed Bankart or Bankart with Hill-Sachs lesions. Patients underwent arthroscopic Bankart repair with or without remplissage based on the inclusion criteria of this study. Preoperative assessments included demographics, history, physical examination, American Shoulder and Elbow Surgeons (ASES) score, Quick Disabilities of the Arm, Shoulder, and Hand (DASH) score, ROWE score, and plain MRI of the shoulder joint. Post-operative radiographs and rehabilitation were advised. Functional recovery was evaluated at three months and six months after surgery. Results All patients underwent Bankart repair. Among them, 22 with engaging Hill-Sachs lesions received an additional remplissage procedure. Both groups showed significant improvements in their functional scores (p<0.05) and returned to their prior activities. However, the additional remplissage group had a slightly reduced mean external rotation (86.59°) compared with the Bankart repair-only group (90°). Notably, the recurrence rate was very low, with only one patient (2.5%) experiencing instability. Conclusion  Our study emphasizes the importance of proper capsulolabral tissue elevation to achieve a sufficient labral bump during Bankart repair. This technique allowed us to efficiently use only two suture anchors in 35 cases (87.5%). Additionally, remplissage was performed on all identified engaging Hill-Sachs lesions. We found that proper anchor placement and suturing techniques were crucial for successful Bankart repair. The emphasis on the potential cost benefits of a two-anchor approach is a valuable contribution to the field.

Studies on Bankart Repair for Anterior Shoulder Instability Show Poor Reporting of Data and Reflect Low Level of Evidence: A Systematic Review

PURPOSE

To assess the quality and level of evidence of studies reporting on Bankart repair for anterior shoulder instability.

METHODS

A search was performed using the PubMed/Medline database for all studies that reported clinical outcomes on Bankart repair for anterior shoulder instability. The search term "Bankart repair" with all results were analyzed via strict inclusion and exclusion criteria. Two independent investigators scored each included study based on the 10 criteria of the Modified Coleman Methodology Score (CMS) out of 100 and gave each study a score out of 25 based on the Anterior Shoulder Instability (ASI) Methodology criteria.

RESULTS

Two hundred sixty-six studies were included in the analysis and encompassed a total of 19,156 patients and 19,317 surgical procedures for Bankart repair for shoulder instability. Overall, 81.6% of studies were Level III or IV evidence. The mean CMS score for the studies was 55.3 out of 100, and the mean ASI Methodology score for the studies was 12.1 out of 25. Weaknesses in the studies were identified in sample size, description of preoperative investigations and diagnoses, reporting of mean glenoid bone loss, nonsubjective clinical outcome reporting, and description of associated pathologies.

CONCLUSIONS

A large proportion of studies reporting the clinical outcomes of Bankart repair for anterior shoulder instability are of low methodological quality and have a low level of evidence.

CLINICAL RELEVANCE

This study emphasizes need for greater reporting of many variables such as body mass index, mean glenoid bone loss, and patient-reported outcomes and provides a framework for future studies reporting.

A comprehensive comparison and evaluation of surgical techniques for anterior shoulder instability: a Bayesian network meta-analysis

BACKGROUND

Anterior shoulder instability is a common clinical problem; however, conflicting evidence exists regarding optimal treatment algorithms. We perform a comparative analysis of stabilization techniques used for recurrent anterior shoulder instability to identify the one associated with the lowest rate of recurrent instability. We additionally explore how glenoid bone loss and osseus lesions affect recurrence rates.

METHODS

PubMed, MEDLINE, Embase, and Cochrane databases were searched for clinical studies comparing surgical techniques for anterior shoulder instability. Two team members independently assessed all potential studies for eligibility and extracted data. Each included study underwent a risk of bias assessment using the Cochrane risk of bias summary tool. The primary outcome of interest was the rate of recurrent instability, which underwent a Bayesian network meta-analysis. Additional analyses were performed relating to the degree of glenoid bone loss and the presence of osseous lesions.

RESULTS

Of 2699 studies screened, 52 studies with 4209 patients were included. Patients who underwent open Latarjet demonstrated the overall lowest rate of recurrent instability [log odds ratio (LOR) 1.93], whereas patients who underwent arthroscopic Bankart repair demonstrated the highest (LOR 2.87). When glenoid bone loss was 10% to 20%, open Latarjet had significantly lower recurrent instability (P = .0016) compared to arthroscopic Bankart repair. When glenoid bone loss increased from 0%-10% to 10%-20%, arthroscopic Bankart repair had a significantly increased rate of recurrence (P = .021). In the presence of an engaging Hill-Sachs lesion, both open Latarjet (P = .01) and arthroscopic Bankart with remplissage (P = .029) had significantly reduced recurrence rates compared to arthroscopic Bankart repair. Finally, regardless of procedure, the presence of a Hill-Sachs or bony Bankart lesion was associated with an increased risk of recurrent instability (r = 0.44, P = .0003, and r = 0.40, P = .006, respectively).

CONCLUSION

The open Latarjet has the overall lowest recurrent instability and significantly lower compared to arthroscopic Bankart repair in the setting of increasing glenoid bone loss. Bone loss between 0% and 10% results in similar outcomes across all procedures.

Global variations in treatment and outcomes reported for anterior shoulder instability: a systematic review of the literature

Background

Anterior shoulder instability is a common problem around the world, with a high risk for recurrence following the index dislocation. Surgical stabilization is commonly indicated for persistent instability, particularly in patients at high risk for recurrence, to minimize the risk of further labral injury and glenoid bone loss. However, there is little known about global geographic differences in the surgical management of anterior shoulder instability. As such, the purpose of this study was to evaluate and systematically review regional differences in the surgical treatment of anterior shoulder instability, particularly the indications for and outcomes from bony stabilization procedures compared to soft tissue procedures.

Methods

A systematic review, in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, was performed. Inclusion criteria consisted of level I and II evidence studies evaluating indications, techniques, and outcomes following operative management of anterior shoulder instability published from January 2000 to September 2021. Studies meeting inclusion criteria were grouped into four global regions (Asia, Europe, North America, South America) based on primary study location. Patient demographics, procedural details, patient reported outcomes, and complications (recurrence and reoperation rates) were compared between regions.

Results

Sixty (n = 60) studies (5480 patients) were identified. Eighty-six percent of all patients were male, with a mean age of 26.7 years. There was no difference in mean patient age, though patients undergoing bony stabilization procedures were older than those undergoing soft-tissue stabilization procedures (P = .0002) in all regions. The proportion of bony versus soft-tissue procedure groups did not differ significantly among regions. The indications for bony stabilization procedures varied significantly. Mean final follow-up was 3.5 years. Recurrent instability was 5.0% and did not vary across regions. However, recurrent instability occurred more frequently following soft-tissue compared to bony stabilization procedures (P = .017). South American studies utilized fewer anchors during soft tissue stabilization (P < .0001) and reported a higher reoperation rate compared to other regions (P = .009).

Conclusion

There is global variation in the reporting of outcomes following surgery for anterior shoulder instability. The proportion of bony and soft-tissue procedures is similar, irrespective of geographic region. Recurrent instability does not vary by region but occurs more frequently following soft-tissue compared to bony stabilization procedures. There are a number of potential medical and nonmedical factors that may affect global variation in the surgical treatment of anterior shoulder instability.

Results of arthroscopic treatment for anteroinferior shoulder instability using a single anterior working portal using birdbeak

BACKGROUND

The shoulder joint is the joint with the most dislocations in all joints. The arthroscopic surgery method is considered the gold standard because it creates less soft tissue damage, shorter hospitalization and surgery time, and less restriction of movement after surgery in shoulder instability. Anterior single portal technique has become popular recently. In this study, it was aimed to evaluate the results of the anterior single portal repair technique using "birdbeak". We try to evaluate if this technique is a reliable technique and has the same or more advantages of two portal arthroscopic surgery and make the surgery easier for surgeons.

METHODS

In the total of 40 patients who underwent arthroscopic surgery for traumatic recurrent anterior shoulder dislocation between January 2017 and February 2020, this study included 19 patients with the surgical technique of arthroscopic isolated anterior labrum tear repair using a birdbeak from the anterior single working portal. Clinical results were evaluated with the Simple Shoulder Test (SST), Rowe Score for Instability (RWS) and Oxford Shoulder Instability Score (OSIS) tests before and after surgery. The relationship between the time to surgery after the first dislocation and clinical outcomes was also examined in the study. Kolmogorov-Smirnov and Shapiro-Wilk tests were used to control the assumption of normality. In addition, Pearson correlation and Spearman correlation analyzes were used to test the relationship between the variables.

RESULTS

The mean follow-up period of the 19 patients included in this study was 33.1 months. The mean time to surgery after the first dislocation was 18.4 months. The mean preoperative number of dislocations was 5.3. The mean number of anchors used in the repair was 2.1. No recurrent dislocations were observed after surgery. A significant difference was observed between preoperative and postoperative SST, RWS and OSIS scores (respectively, p = 0.000 < 0.001, p = 0.000 < 0.001, p = 0.000 < 0.001). There was no statistically significant relationship between the time elapsed after the first dislocation and the postoperative SST, RWS, OSIS scores (respectively, p = 0.43 > 0.05, p = 0.39 > 0.05, p = 0.31 > 0.05).

CONCLUSION

It has been observed that the repair technique applied using the "birdbeak" from the anterior single working portal is a successful treatment, and further studies are required due to the limited literature.

Outcomes After Arthroscopic Revision Bankart Repair: An Updated Systematic Review of Recent Literature

PURPOSE

To provide an update of recent literature with a specialized focus on clinical outcomes following arthroscopic revision Bankart repair (ARBR) by performing a systematic review of all available literature published between 2013 and 2020.

METHODS

A literature search reporting clinical outcomes after ARBR was performed. Criteria for inclusion consisted of original studies; Level of Evidence of I-IV; studies focusing on clinical outcomes after ARBR published between January 1, 2013, and January 4, 2021; studies reporting recurrent dislocation or instability rate after ARBR; reoperation/revision following ARBR, return to sport rates following ARBR; and patient-reported outcomes. The primary outcomes of interest were failure defined as recurrent instability or dislocation, return to sport rates, and patient-reported outcomes at follow-up.

RESULTS

A large proportion of patients undergoing arthroscopic revision Bankart repair were male, ranging between 67.7% and 93.8%. Failure rate and return to sports rate ranged between 6.1% and 46.8% and 25.9% and 88.3%, respectively, when patients with significant or greater than 20% glenoid bone loss was excluded. Patient-reported outcome scores, which included American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale, saw significant improvement over mean follow-up of ranging 21.64 to 60 months.

CONCLUSIONS

Both the failure rate and RTS rates after ARBR had a wide range, given the heterogeneity of the studies included, which varied in patient selection criteria pertaining to patients with greater than 20% glenoid bone. Although there have been advancements in arthroscopic techniques and a trend favoring arthroscopic stabilization procedures, there is a lack of consensus in recent literature for careful patient selection criteria that would minimize failure rates and maximize RTS rates after ARBR.

LEVEL OF EVIDENCE

Level IV, a systematic review of Level III-IV studies.

A Case Series of Whether Arthroscopic Bankart Repair Following Primary Traumatic Anterior Shoulder Dislocation Versus Recurrent Dislocation in Soldiers Has Any Effect on the Postoperative Recurrence Rate

Background

Anterior traumatic shoulder dislocation is very common among soldiers or any young population following injury, which is invariably treated by closed reduction. The dislocation when treated nonsurgically has a 71% high rate of recurrence. There is not much data available on the rate of recurrence when primary dislocation (first time) was treated by arthroscopic Bankart repair and in those who have recurrent (multiple) dislocations before surgery.

Aim

This study aims to report the postoperative recurrence rate in soldiers with first-time dislocation versus those with recurrent dislocations before surgery.

Study design

The present study is a level IV case series treatment study.

Methods

In this prospective study, 143 soldiers were included, of which 82 patients had first-time dislocation (F group) and 61 patients had recurrent dislocation before surgery (R group). The patients were evaluated and followed up for over three years. Nonabsorbable PEEK suture anchors (Chetan Meditech, India) were used for arthroscopic Bankart repair. The recurrence rates, Rowe scores, visual analog scale (VAS) scores, subjective shoulder values (SSVs), and satisfaction were compared. We also used the Simple Shoulder Test (SST) score for evaluation. The scores were recorded preoperatively and at three-year follow-up. The range of motion, postoperative function, recurrence rates, and return to pre-injury state was evaluated.

Results

A total of 143 patients were included, providing 97.3% follow-up at an average of 36 months. The postoperative recurrence rate was 19.7% in the F group and 58.3% in the R group (P < 0.001). The odds of postoperative recurrence were five times higher in the recurrent dislocation group (odds ratio (OR): 5.23).

Conclusion

Patients who underwent repair after first-time dislocation show a lower postoperative recurrence rate as compared with those who had multiple dislocations before surgery. It is prudent to advise early repair even after the first dislocation especially in young active soldiers to reduce the risk of postoperative recurrence.

The Fragility Index of Statistically Significant Findings From Randomized Controlled Trials Comparing the Management Strategies of Anterior Shoulder Instability

BACKGROUND

Debate centering on the management of anterior shoulder instability (ASI) in recent years has led to many randomized controlled trials (RCTs) being published on the topic. The fragility index (FI) has subsequently emerged as a novel method of assessing significant findings reported in RCTs, particularly those with small sample sizes.

PURPOSE

To evaluate the FI of statistically significant findings in RCTs that reported the outcomes of management strategies of patients with ASI.

STUDY DESIGN

Systematic review; Level of evidence, 1.

METHODS

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent reviewers performed a systematic review of RCTs focusing on the outcomes of management strategies of patients with ASI. There were 3 main categories of RCTs included: (1) nonoperative management in internal rotation (IR) versus external rotation (ER), (2) nonoperative management versus a surgical intervention, and (3) surgical management with arthroscopic Bankart repair versus open Bankart repair. The Fisher exact test was utilized to calculate the FI for the reversal of statistical significance in all statistically significant dichotomous outcomes.

RESULTS

A total of 21 RCTs were included, including 1589 shoulders (mean age, 29.4 years) with a mean follow-up of 26.8 months. There were 10 RCTs (831 shoulders) that reported outcomes after the nonoperative management of ASI in IR versus ER, with a mean FI of 6.8. There were 5 RCTs (324 shoulders) that reported outcomes comparing the nonoperative and operative management of ASI, with a mean FI of 3.5. There were 6 RCTs (434 shoulders) that reported outcomes after the operative management of ASI with either arthroscopic Bankart repair or open Bankart repair, with a mean FI of 9.6.

CONCLUSION

The overall FI of RCTs reporting the outcomes of management strategies for patients with ASI was high, suggesting a moderate fragility of statistically significant outcomes including recurrence, revision stabilization, and return to play.

Revision Arthroscopic Bankart Repair for Anterior Shoulder Instability After a Failed Arthroscopic Soft-Tissue Repair Yields Comparable Failure Rates to Primary Bankart Repair: A Systematic Review

BACKGROUND

The management of recurrent instability after arthroscopic Bankart repair remains challenging. Of the various treatment options, arthroscopic revision repairs are of increasing interest due to improved visualization of pathology and advancements in arthroscopic techniques and instrumentation.

PURPOSE

We sought to assess the indications, techniques, outcomes, and complications for patients undergoing revision arthroscopic Bankart repair after a failed index arthroscopic soft-tissue stabilization for anterior shoulder instability.

METHODS

We performed a systematic review of studies identified by a search of Medline, Embase, and PubMed. Our search range was from data inception to April 29, 2020. Outcomes include clinical outcomes and rates of complication and revision. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Data are presented descriptively.

RESULTS

Twelve studies were identified, comprising 279 patients (281 shoulders) with a mean age of 26.1 ± 3.8 years and a mean follow-up of 55.7 ± 24.3 months. Patients had improvements in postoperative outcomes (eg, pain and function). The overall complication rate was 29.5%, the most common being recurrent instability (19.9%).

CONCLUSION

With significant improvements postoperatively and comparable recurrent instability rates, there exists a potential role in the use of revision arthroscopic Bankart repair where the glenoid bone loss is less than 20%. Clinicians should consider patient history and imaging findings to determine whether a more rigorous stabilization procedure is warranted. Large prospective cohorts with long-term follow-up and improved documentation are required to determine more accurate failure rates.

Editorial Commentary: Early Detection and Treatment Improves Short-Term Outcomes After Shoulder Anchor Arthropathy, but an Ounce of Prevention Is Worth a Pound of Cure

Anchor arthropathy is a rare, but devastating, complication after arthroscopic labral repair and shoulder stabilization. Early recognition and treatment in the form of removal of anchor and suture material, loose bodies, and potential revision stabilization significantly improve short-term outcomes. The entity of anchor arthropathy may be difficult to diagnose, and a high index of suspicion is needed when a patient presents postoperatively with pain and stiffness beyond atypical for their time in rehab. In the end, while early treatment can be favorable, prevention with meticulous attention to detail on anchor placement, position, and potential use of knotless anchors is strongly recommended.

Patient Willingness to Pay for Faster Return to Work or Smaller Incisions

Background: Value-based health care models such as bundled payments and accountable care organizations can penalize health systems and physicians for excess costs leading to low-value care. Health systems can minimize these extra costs by constraining diagnostic (eg, magnetic resonance imaging utilization) or treatment options with debatable necessity in the setting of clinical equipoise. Instead of restricting more expensive treatments, it is plausible that health systems could instead recoup the extra costs of these treatments by charging patients supplementary out-of-pocket charges (cost sharing). The primary aim of this exploratory study was to assess hand surgery patient willingness to pay supplementary out-of-pocket charges for a procedure that theoretically leads to an earlier return to work or smaller incisions when there are 2 procedures that lead to similar results (clinical equipoise). Methods: A total of 122 patients completed a questionnaire that included demographic information, a financial distress assessment, a series of scenarios asking patients the degree to which they are willing to pay extra for the procedure choice, as well as their perspective of how much insurers should be responsible for these additional costs. Results: Patients were willing to pay out-of-pocket to some degree for a procedure that leads to earlier return to work and smaller incision size when compared with a similar alternative procedure, but noted that insurers should bear a greater burden of costs. Approximately 10% of patients were willing to pay maximum amounts ($2500+) for earlier return to work (3, 7, and 14 days earlier) and smaller incision sizes of any length. Conclusions: Some patients may be willing to pay out-of-pocket and cost share for procedures that lead to earlier return to work and smaller incisions in the setting of clinical equipoise. As such, when developing and implementing alternative payment models, health systems could potentially offer services with debatable necessity in the setting of equipoise for a supplementary out-of-pocket charge.

Management of shoulder instability in hypermobility-type Ehlers-Danlos syndrome

Shoulder instability in hypermobile Ehlers-Danlos syndrome can result in lifelong pain and functional disability. Treatment in this population is complicated by the severe degree of instability as well as the underlying abnormalities of the joint connective tissue. Appropriate care for these patients requires a thorough understanding of the natural history of their disease, knowledge of the available treatment options, and certain special considerations. This article reviews the pathoanatomy, recognition, and management of shoulder instability in the patient with hypermobile Ehlers-Danlos syndrome.

Arthroscopic Versus Open Anterior Shoulder Stabilization: A Prospective Randomized Clinical Trial With 15-Year Follow-up With an Assessment of the Glenoid Being "On-Track" and "Off-Track" as a Predictor of Failure

BACKGROUND

Recent studies have demonstrated equivalent short-term results when comparing arthroscopic versus open anterior shoulder stabilization. However, none have evaluated the long-term clinical outcomes of patients after arthroscopic or open anterior shoulder stabilization, with inclusion of an assessment of preoperative glenoid tracking.

PURPOSE

To compare long-term clinical outcomes of patients with recurrent anterior shoulder instability randomized to open and arthroscopic stabilization groups. Additionally, preoperative magnetic resonance imaging (MRI) studies were used to assess whether the shoulders were "on-track" or "off-track" to ascertain a prediction of increased failure risk.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Follow-up assessments were performed at minimum 15-year follow-up using established postoperative evaluations. Clinical failure was defined as any recurrent dislocation postoperatively or subjective instability. Preoperative MRI scans were obtained to calculate the glenoid track and designate shoulders as on-track or off-track. These results were then correlated with the patients' clinical results at their latest follow-up.

RESULTS

Of 64 patients, 60 (28 arthroscopic and 32 open) were contacted or examined for follow-up (range, 15-17 years). The mean age at the time of surgery was 25 years (range, 19-42 years), while the mean age at the time of this assessment was 40 years (range, 34-57 years). The rates of arthroscopic and open long-term failure were 14.3% (4/28) and 12.5% (4/32), respectively. There were no differences in subjective shoulder outcome scores between the treatment groups. Of the 56 shoulders, with available MRI studies, 8 (14.3%) were determined to be off-track. Of these 8 shoulders, there were 2 surgical failures (25.0%; 1 treated arthroscopically, 1 treated open). In the on-track group, 6 of 48 had failed surgery (12.5%; 3 open, 3 arthroscopic [P = .280]).

CONCLUSION

Long-term clinical outcomes were comparable at 15 years postoperatively between the arthroscopic and open stabilization groups. The presence of an off-track lesion may be associated with a higher rate of recurrent instability in both cohorts at long-term follow-up; however, this study was underpowered to verify this situation.

The 50 Most-Cited Papers on Bankart Lesions

Purpose

To analyze the 50 most-cited articles pertaining to “Bankart lesions,” also known as anteroinferior labral tears, by means of citation analysis as well as to provide analysis and summary of the origins and trends of research on Bankart lesions.

Methods

Scopus was used to query the literature on Bankart lesions. Included articles were related to Bankart lesions and the indications, risk factors, techniques, and outcomes of arthroscopic and open Bankart repair. The 50 most-cited articles were analyzed in the following areas: year of publication, citations in the most recent year, total citation count, contributing authors, institutions, countries, and journals, article classifications, and level of evidence.

Results

Years of publication ranged from 1938 to 2013. There were 608 total citations in the most recent year. Total citation count was 12,441. Regarding country, journal, and authorship, United States, R. A. Arciero, and Arthroscopy were the highest respective contributors. Rush University had the greatest number of publications. The most common article classification was clinical outcomes. Of 49 clinical articles, the most frequent Level of Evidence was IV. The majority of the top 50 Bankart literature consisted of case series and retrospective studies performed in the United States.

Conclusions

Our findings are consistent with the hypothesis that the 50 most-cited articles about Bankart lesions are predominantly U.S.-based, produced by academic orthopaedic groups, clinical outcomes articles, and of Level IV and V evidence. This list of articles should serve as a reference tool for any orthopaedist looking to review Bankart literature.

Arthroscopic Bankart Repair With and Without Curettage of the Glenoid Edge: A Prospective, Randomized, Controlled Study

PURPOSE

To determine whether curettage of the cartilage on the glenoid edge in arthroscopic Bankart repair reduces the postoperative recurrence rate compared with noncuretted glenoid.

METHODS

Between January 2010 and December 2013, 134 patients underwent arthroscopy and stabilization for recurrent anterior dislocation of shoulder; 42 patients were excluded. Alternate glenoid edge was curetted in 92 patients undergoing arthroscopic Bankart repair. Twelve patients were lost to follow-up. The remaining 80 patients were divided into 2 groups of 40 patients each, curettage and noncurettage. In both groups, the Bankart lesion was repaired using ≥3 bioanchors loaded with nonabsorbable braided sutures. Postoperative rehabilitation was the same for the 2 groups. We recorded recurrence of instability, pain, and Constant and Rowe shoulder scores. Statistical analysis of data was performed using unpaired t test (significance level P < .05).

RESULTS

The 2 groups were comparable in terms of age, number of dislocations, and bone loss. The average follow-up was 7 years and 9 months (range 6 to 10 years). Of the total 40 patients in the curettage group, 6 (15%) had recurrence of dislocation and none had subluxations, whereas in the noncurettage group, 13 (32.5%) had recurrence of dislocation and 3 (7.5%) had subluxations. The difference in postoperative recurrence of instability was statistically significant (P = .012). The average (standard deviation) Rowe score was 83.75 (23.28) in the curettage group and 70.13 (31.29) in the noncurettage group (P = .030).

CONCLUSIONS

During arthroscopic Bankart repair, curettage of the cartilage on the anterior glenoid edge reduces the incidence of postoperative recurrence of instability.

LEVEL OF EVIDENCE

II, therapeutic; prospective, randomized, controlled study.

The Top 50 Most-Cited Shoulder Arthroscopy Studies

Purpose

To determine the 50 most frequently cited studies in the orthopaedic shoulder arthroscopy literature and to conduct a bibliometric analysis of these studies.

Methods

The Clarivate Analytics Web of Knowledge database was used to gather data and metrics using Boolean queries to capture all possible iterations of shoulder arthroscopy research. The search list was sorted so that articles were organized in descending order based on the number of citations and included or excluded based on relevance to shoulder arthroscopy. The information extracted for each article included author name, publication year, country of origin, journal name, article type, and the level of evidence.

Results

For these 50 studies, the total number of citations was calculated to be 13,910, with an average of 278.2 citations per paper. The most-cited article was cited 1134 times, whereas the second- and third-most cited articles were cited 920 and 745 times, respectively. All 50 articles were published in English and came from 7 different orthopaedic journals. The United States was responsible for most of the included articles (31), followed by France (9) and Japan (3).

Conclusions

The majority of the most-cited articles in shoulder arthroscopy are case series and descriptive studies originating from the United States. In addition, more than one half of the top 50 most-cited studies were published after 2004, which suggests that article age may be less important in the accumulation of citations for a rapidly growing field like shoulder arthroscopy.

Clinical Relevance

The top 50 most-cited studies list will provide researchers, medical students, residents, and fellows with a foundational list of the most important and influential academic contributions to shoulder arthroscopy.

Anterior glenohumeral instability: Current review with technical pearls and pitfalls of arthroscopic soft-tissue stabilization

The glenohumeral joint (GHJ) allows for a wide range of motion, but is also particularly vulnerable to episodes of instability. Anterior GHJ instability is especially frequent among young, athletic populations during contact sporting events. Many first time dislocators can be managed non-operatively with a period of immobilization and rehabilitation, however certain patient populations are at higher risk for recurrent instability and may require surgical intervention for adequate stabilization. Determination of the optimal treatment strategy should be made on a case-by-case basis while weighing both patient specific factors and injury patterns (i.e., bone loss). The purpose of this review is to describe the relevant anatomical stabilizers of the GHJ, risk factors for recurrent instability including bony lesions, indications for arthroscopic vs open surgical management, clinical history and physical examination techniques, imaging modalities, and pearls/pitfalls of arthroscopic soft-tissue stabilization for anterior glenohumeral instability.

First-time Glenohumeral Dislocations: Current Evidence and Considerations in Clinical Decision Making

The decision to manage first-time shoulder dislocations conservatively or operatively has become increasingly complex because of conflicting literature. Although shoulder dislocations have traditionally been managed with reduction and immobilization, recent evidence has suggested high rates of subsequent recurrence. Surgical intervention is thought to better restore stability and decrease recurrence rates; however, it also has the potential for additional morbidity and financial cost. As such, recent literature has sought to better define patient risk profiles to identify optimal candidates for both conservative and operative management. The purpose of the current review is to provide a comprehensive and evidence-based assessment of the most recent literature to better delineate an appropriate treatment algorithm for this challenging clinical scenario.

Revision Arthroscopic Bankart Repair: A Systematic Review of Clinical Outcomes

Although the frequency of arthroscopic revision surgery is increasing in patients with recurrent dislocation after a primary shoulder stabilization, the literature describing arthroscopic revision Bankart repair has been limited. Preferred reporting items for systematic meta-analyses guidelines were followed by utilizing PubMed, EMBASE, Scopus, and Cochrane Library databases. Keywords included shoulder dislocation, anterior shoulder instability, revision surgery, stabilization, and arthroscopic Bankart repair. Quality assessments were performed with criteria from the methodological index for nonrandomized studies (MINORS). A total of 14 articles were included in this analysis. The mean MINORS score was 12.43. A total of 339 shoulders (337 patients) were included (281 males and 56 females). The mean follow-up period was 36.7 months. Primary surgeries were as follows: arthroscopic procedures (n = 172, 50.7%), open procedure (n = 87, 25.7%), and unknown (n = 80, 23.6%). The mean rate of recurrent instability after revision arthroscopic Bankart repair was 15.3% (n = 52), and an additional re-revision procedure was needed in 6.5% of cases (n = 22). Overall, there were 18.0% (n = 61) of complications reported. This systematic review suggests that arthroscopic revision Bankart repair can lead to an improvement in functional outcomes and reasonable patient satisfaction with proper patient selection.

Comprehensive Arthroscopic Shoulder Stabilization in the Lateral Decubitus Position

Arthroscopic shoulder stabilization offers a safe and effective means for restoring glenohumeral mechanics in the setting of shoulder instability. Modern arthroscopic techniques have allowed improved access and efficiency when treating patients with shoulder instability. However, access to certain areas of the labrum and the creation of safe accessory portals can still prove difficult for the arthroscopic surgeon. Currently, there is debate as to the ideal patient position, portal location, equipment, and technique for addressing anterior-inferior labral pathology. The following article presents a safe and effective approach to accessing the labrum for treatment of shoulder instability in the lateral decubitus position. In addition, this paper highlights the use of accessory portals, including a percutaneous "7-o'clock" portal for suture anchor placement, along with multiple types of suture anchor and suture shuttling techniques.

Arthroscopic Bankart repair with knotless suture anchors: A comparison of the permanent and absorbable types

Aim:

The aim of this study was to compare the clinical outcomes of arthroscopic Bankart repair (ABR) using two types of knotless suture anchors (KSAs) in patients with post-traumatic recurrent anterior glenohumeral instability (AGHI).

Methods:

Thirty-two patients underwent an ABR using KSAs: a permanent KSA (PushLock) and an absorbable counterpart (BioKnotless). There were 16 patients in each group. Pre-and post-operative assessment for shoulder function using the American Shoulder and Elbow Surgeons and Constant–Murley scores, recurrence of instability, post-operative limitation of external rotation (ER) and ability to return to pre-injury level were recorded in both groups.

Results:

Both groups displayed significant improvements in functional scores ( p < 0.0001) without a significant difference between the groups. Of the 32 patients, 9.4% had recurrence of instability (one re-dislocation in group 1 and two symptomatic subluxations in group 2). Return to pre-injury level occurred in 87.5% and 81.3% of group 1 and group 2, respectively. There was 2° to 3° loss of ER after ABR in both groups; the difference between the groups was not significant ( p = 0.45).

Conclusion:

ABR for recurrent AGHI using a permanent or absorbable KSA offers comparable successful outcomes; no significant statistical difference was found.

Differences in Failure Mode Between Simple and Mattress Suture Configuration in Arthroscopic Bankart Repairs: A Cadaveric Study

Background

Traumatic anterior shoulder dislocations disrupt the anteroinferior labrum (Bankart lesion), leading to high rates of instability and functional disability, necessitating stabilization.

Purpose

To investigate modes and locations of repair failure between simple and horizontal mattress suture configurations after arthroscopic Bankart repair using suture anchors in a cadaveric model.

Study Design

Controlled laboratory study.

Methods

A total of 48 fresh-frozen human cadaveric shoulders from 48 specimens underwent creation of Bankart lesions from either the 3:00 to 6:00 o'clock position on the right glenoid or the 6:00 to 9:00 o'clock position on the left glenoid. Shoulder laterality between specimens was alternated and randomized to either simple or mattress suture repair configurations. In each shoulder, anchors were placed on the glenoid at the 3:00, 4:30, and 6:00 o'clock positions on the right or 6:00, 7:30, and 9:00 o'clock positions on the left and were secured via standard arthroscopic knot-tying techniques. Specimens were tested in the supine anterior apprehension position using a servohydraulic testing machine that was loaded to failure, simulating a traumatic anterior dislocation. After dislocation, open inspection of specimens was performed, and failure mode and location were documented. Differences in failure mode and location were compared using nominal multivariate generalized estimating equations.

Results

Simple suture repairs most frequently failed at the labrum, while mattress suture repair failed at the capsule. Regardless of configuration, repairs failed most commonly at the 3:00 o'clock position on the right shoulder and 9:00 o'clock position on the left shoulder. Compared with mattress suture repairs, simple suture repairs failed at a significantly higher rate at the 6:00 o'clock position.

Conclusion

Traumatic anterior shoulder dislocation after arthroscopic Bankart repair in a cadaveric model resulted in simple suture configuration repairs failing most commonly via labral tearing compared with capsular tearing in mattress repairs. Both repair configurations failed predominately at the anterior anchor position, with simple suture repairs failing more commonly at the inferior anchor position.

Clinical Relevance

Horizontal mattress suture configurations create a larger area of repair, decreasing the risk of repair failure at the labrum. The extra time required for mattress suture placement at the inferior anchor position is used effectively, resulting in lower biomechanical failure rates.

Arthroscopic stabilisation for shoulder instability

Since its first description over 30 years ago arthroscopic stabilisation has evolved. With improvements in knowledge, surgical techniques and materials technology, arthroscopic bankart repair has become the most widely used method for treating patients with symptomatic anterior shoulder instability. These procedures are typically performed in a younger, high demand patient population after a primary dislocation or to treat recurrent instability. A thorough clinical evaluation is required in the clinic setting not only to fully understand the injury pattern but also consider patient expectations prior to embarking on surgery. Diagnostic imaging will aid the clinician in determining the soft tissue pathology as well as assessing bone loss, which facilitates surgical decision-making. Selected patients may benefit from adjunctive procedures such as a remplissage for an "engaging" Hill-sachs lesion. This review will focus on the indications, pre-operative considerations, surgical techniques and outcomes of arthroscopic stabilisation.

Does anchor insertion angle or placement of the suture anchor affect glenoid rim fracture occurrence after arthroscopic Bankart repair?

BACKGROUND

The purposes were to compare the characteristics of 2 groups of patients who underwent revision Bankart repair with and without glenoid rim fractures and to examine risk factors for glenoid rim fractures.

METHODS

We retrospectively analyzed 39 patients who needed revision surgery after arthroscopic Bankart repair and identified 19 patients with and 20 patients without glenoid rim fractures. The insertion angle of the suture anchor, anchor position on the glenoid, and demographic data were compared between the groups.

RESULTS

The mean anchor insertion angles in the glenoid fracture group (group F) at the 2-, 3-, 4-, and 5-o'clock positions were 64°, 58°, 55°, and 55°, respectively; those in the no-fracture group (group R) were 60°, 63°, 60°, and 55°, respectively (P = .630, P = .207, P = .166, and P = .976, respectively). At the 5-o'clock position, anchors were fixed to the glenoid face in 13 cases in group F and in 3 cases in group R (P = .040). Although age (P = .529) and sex (P = 1.0) did not differ between the groups, elite and professional athletes had a significantly higher incidence of glenoid rim fractures (P = .009).

CONCLUSION

The anchor insertion angle did not affect glenoid rim fracture occurrence after arthroscopic Bankart repair. However, the placement of the suture anchor at the 5-o'clock position on the glenoid face could increase the risk of glenoid rim fracture after trauma. Athletes were more likely to have glenoid rim fractures owing to major trauma after arthroscopic Bankart repair.

Mid-term to long-term results of primary arthroscopic Bankart repair for traumatic anterior shoulder instability: a retrospective study

Background

The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. The aim of the study is to determine the mid−/long-term functional outcome, failure rates and predictors of failure after primary arthroscopic Bankart repair for traumatic anterior shoulder instability.

Methods

A total of 100 patients were primarily operated using arthroscopic Bankart repair after traumatic anterior shoulder instability. Medical records were retrospectively reviewed, and patients were assessed using postal questionnaire after a mean follow-up of 8.3 years [3–14]. Clinical assessment was performed using Constant score, Rowe score, and American Shoulder and Elbow Surgeons score.

Results

The overall recurrence rate was 22%. The Kaplan-Meier failure-free survival estimates.

were 80% at 5 years and 70% at 10 years. Nearly half (54.5%) of recurrences occurred at 2 years postoperative. Compared with normal shoulder, there were statistical differences in all 3 scores. Failure rate was significantly affected by age at the time of surgery with 86% of recurrence cases observed in patients aged 30 years or younger. Nevertheless, Younger age at the time of surgery (P = 0.007) as well age at the time of initial instability (P = 0.03) was found to correlate negatively with early recurrence within 2 years of surgery. Among those with recurrent instability, recurrence rate was found to be higher if there had been more than 5 instability episodes preoperatively (P = 0.01). Return to the preinjury sport and occupational level was possible in 41 and 78%, respectively.

Conclusion

Failure-free survival rates dropped dramatically over time. Alternative reconstruction techniques should be considered in those aged ≤30 years due to the high recurrence rate.

A Biomechanical Comparison of Two Techniques of Latarjet Procedure in Cadaveric Shoulders

Traumatic anterior instability of the shoulder is commonly treated with the Latarjet procedure, which involves transfer of the coracoid process with a conjoint tendon to the anterior aspect of the glenoid. The two most common techniques of the Latarjet are the classical and congruent arc techniques. The aim of this study was to evaluate the difference in force required to dislocate the shoulder after classical and congruent arc Latarjet procedures were performed. Fourteen cadaveric shoulders were dissected and osteotomised to produce a bony Bankart lesion of 25% of the articular surface leading to an “inverted pear-shaped” glenoid. An anteroinferior force was applied whilst the arm was in abduction and external rotation using a pulley system. The force needed to dislocate was noted, and then the shoulders underwent coracoid transfer with the classical and congruent arc techniques. The average force required to dislocate the shoulder after osteotomy was 123.57 N. After classical Latarjet, the average force required was 325.71 N, compared with 327.14 N after the congruent arc technique. This was not statistically significant. In this biomechanical cadaveric study, there is no difference in the force required to dislocate a shoulder after classical and congruent arc techniques of Latarjet, suggesting that both methods are equally effective at preventing anterior dislocation in the position of abduction and external rotation.

Novel and effective arthroscopic extracapsular stabilization technique for anterior shoulder instability-BLS

PURPOSE

Arthroscopic Bankart repair for the treatment of anterior shoulder instability is associated with a high rate of recurrent instability. Extracapsular stabilization of the glenohumeral joint with enhancement of anterior wall soft tissues may be an effective alternative treatment technique. The aim of this study is to retrospectively assess clinical outcomes in the treatment of anterior shoulder instability using a novel technique of anterior extracapsular stabilization-"between glenohumeral ligaments and subscapularis tendon" (BLS).

METHODS

Patients with anterior shoulder instability who underwent surgical treatment with a novel arthroscopic BLS technique between 2008 and 2016 were eligible for inclusion. According to the level of glenoid bone loss, patients were separated into four groups. Group 1 comprised patients with GBL equal to or less than 5%, group 2 patients with GBL 6-10%, group 3 patients with GBL 11-15%, and group 4 patients with GBL > 15%. A positive outcome in this study was defined as full restoration of joint stability. To evaluate clinical results, preoperative range of ER and IR measured in 90 degrees of abduction were compared with ER and IR measured at final follow-up. Additional outcome instruments used consisted of the Constant Score and the Walch-Duplay Score.

RESULTS

A total of 150 patients underwent arthroscopic BLS surgery. During the study period, 50 patients were lost to follow-up and 100 patients were available for final analysis. Mean patient age was 27.5 (± 10.3) years at the time of surgery. Mean duration of follow-up was 82.9 (± 29.4) months. At final assessment, 86 patients (86%) were categorized as having a positive outcome, with full restoration of joint stability. Recurrence of shoulder instability was observed in 14 (14%) patients, including 6 (6%) cases that were associated with major trauma. At final follow-up, the mean Constant Score was 88.2 ± 10.1, compared to 82.9 ± 9.1 preoperatively (p < 0.05). The mean final and mean preoperative Walch-Duplay Scores were 81.5 ± 18.9 and 52.2 ± 11.9, respectively (p < 0.05). There was no statistically significant limitation of external or internal rotation.

CONCLUSIONS

The BLS technique has been shown to be an effective method to anterior shoulder instability in patients without significant glenoid bone loss. It was shown that this technique provides significant improvement in shoulder function without reducing shoulder range of motion.

LEVEL OF EVIDENCE

IV.

Hybrid suture technique vs simple suture technique for antero-inferior labral tears: Two years' clinical outcomes

Background

We previously reported a hybrid suture technique, wherein mattress and simple suturing are used to create Mason-Allen configuration, with low recurrence rates. This comparative study looking at the two years’ clinical outcomes of arthroscopic anterior labral repair using the hybrid suture technique versus simple suture technique.

Methods

We identified 103 patients who underwent arthroscopic anterior labral repair from 2010 to 2015 with 2-year follow-up. The patients were categorized into two groups: hybrid suture technique (65 patients) and simple suture technique (38 patients). Clinical outcomes measures included UCLA shoulder score, Constant Shoulder Score, Numerical Pain Rating Scale, and Oxford Instability score.

Results

Mean age of the patients was 27.02 ± 9.76 years (17–63), with 91 males and 12 females. At 24 months, both groups showed significant improvement in post-operative clinical scores compared to pre-operation. The patients in hybrid sutures technique demonstrated significant improvement in Constant Shoulder Score, UCLA shoulder score and Oxford Instability score compared to simple suture group at 3 months follow up. (121.98 ± 21.05 vs 109.32 ± 21.15, p < 0.05; 65.5 ± 19 vs 57.4 ± 17.6, p < 0.05; 27.3 ± 5.7 vs 23.7 ± 5.0, p < 0.05; 29.3 ± 8.9 vs 33.4 ± 8.2, p < 0.05). The postoperative recurrence rate was comparable between both groups (hybrid suture group 7.81% vs simple suture group 7.84%).

Conclusions

Arthroscopic anterior labral repair with hybrid suture technique offers significant early improvements in clinical scores and low recurrence rate compared to simple suture technique at 2-year follow-up.

Level of evidence

Level III; Retrospective Cohort Design; Treatment study.

Evaluation of the Instability Severity Index score in predicting failure following arthroscopic Bankart surgery in an active military population

BACKGROUND

The Instability Severity Index (ISI) score is a preoperative risk stratification tool used to identify patients at heightened risk of recurrent anterior instability after an arthroscopic Bankart procedure. The primary objective of this study was to validate the utility of the ISI score in predicting failure of primary arthroscopic Bankart surgery in an active-duty military population.

METHODS

A retrospective study was performed to compare all military service members undergoing primary arthroscopic Bankart repairs at a single military treatment facility between 2007 and 2014. The primary outcome of interest was surgical failure due to recurrent instability. The ISI framework was used to stratify each patient for recurrence, and multivariate analysis was performed to evaluate the composite ISI score and individual domains between patients with and patients without failed Bankart repairs.

RESULTS

A total of 131 patients were identified, with a mean patient age of 26.8 years (range, 19-47 years), among whom 42 patients (32%) were identified as having a higher-demand military occupation. At a minimum 2-year follow-up, 34 patients (26%) sustained recurrent anterior shoulder instability. The mean ISI score of patients in the failed Bankart repair group was not statistically different than that of patients with a successful repair (3.41 vs 3.5, P = .74), and no individual ISI domains were identified as independent risk factors for subsequent surgical failure or revision stabilization.

CONCLUSION

Contrary to the findings of previous validation studies, the composite ISI score and its individual risk factors were not predictive of subsequent surgical failure after primary arthroscopic Bankart repair in an active military population.

Cytotoxicity and biomechanics of suture anchors used in labral repairs

Background

Biodegradable suture anchors are associated with higher redislocation rates. This study examined whether the biocompatibility and/or biomechanical properties of suture anchors contribute to the increase in complications.

Methods

Human glenohumeral capsule cells were cultured with 4 types of suture anchors, Opus LabraFix (titanium alloy; ArthroCare, Austin, TX, USA), PushLock (poly-ether-ether-ketone; Arthrex, Naples, FL, USA), BioKnotless (poly-l-lactic acid; DePuy Mitek, Warsaw, IN, USA), and Suretac II (polyglycolic acid; Smith & Nephew, London, UK), to measure cell viability and pH. Four groups of 6 ovine shoulders were used to repair the labrum, which was completely detached from the glenoid rim anteroinferiorly and reattached with 2 suture anchors and subject to failure load testing.

Results

In cell culture, BioKnotless at 48 and 72 hours (85.2% ± 2.1% and 84.5% ± 3.6%) and Suretac II groups (33.9% ± 3.1% and 42.8% ± 6.4%) had fewer viable cells compared with control (P = .048). The pH of Suretac II was lower than control (7.51 to 7.65) at 24 hours (7.31 ± 0.08, P = .049), 48 hours (7.25 ± 0.02, P = .046), and 72 hours (7.29 ± 0.04, P = .04). During mechanical testing, 83% of repairs failed by the capsule tearing. Among the anchors, the BioKnotless repair group had a significantly lower failure load (37 ± 5 N) compared with the PushLock (61 ± 7 N), Opus (60 ± 6 N), and Suretac II (57 ± 7 N) groups (P = .038).

Conclusion

BioKnotless and Suretac II anchors are cytotoxic. The BioKnotless biodegradable anchor has significantly lower failure load. Absorbable suture anchors may cause higher redislocation of arthroscopic Bankart repair.

Comparison of Curved and Straight Anchor Insertion for Bankart Repair

The quality of Bankart repair may be compromised by the presence of glenoid perforation during suture anchor placement. The purpose of this study was to compare the rate of glenoid perforation and biomechanical strength of antero-inferior suture anchors placed with a curved vs a traditional straight technique through an anteroinferior portal. Ten bilateral pairs of fresh human cadaveric shoulders were randomized to either a curved or a straight suture anchor insertion technique. An anteroinferior portal was used to place a 1.5-mm soft anchor in the anteroinferior glenoid (5:30 position for right shoulders). Anatomic dissection was performed, and the maximum load of each anchor was measured using a materials testing system. The overall rate of glenoid perforation by the anteroinferior anchor was 50%. The rate of glenoid perforation was 40% in the straight group and 60% in the curved group (P=.41). The median maximum load was 86 N in the straight group and 137 N in the curved group (P=.23). The median maximum load of the anchors that did perforate the glenoid was 102 N and of those that did not was 118 N (P=.72). The mode of failure was suture anchor pullout in all except one specimen. The curved guide was not superior to the traditional straight guide in terms of the rate of glenoid perforation or the maximum load of the suture anchors. Anterior cortical perforation of the glenoid during anteroinferior suture anchor placement is common with both techniques. [Orthopedics. 2019; 42(2):e242-e246.].

Surgical treatment outcomes after primary vs recurrent anterior shoulder instability

INTRODUCTION

The aim of this study is to compare the outcomes of surgical management after primary anterior shoulder dislocation to the outcomes of patients who have surgical stabilization after recurrent anterior shoulder instability.

METHODS

A Medline (PubMed) search was performed in November of 2016 using the following key terms: shoulder, labrum, Bankart, instability, repair, outcome, recurrent. In May 2017 a Cochrane search was performed using similar key terms to ensure we included all studies. Only level I and II studies were included.

RESULTS

There were three studies that compared primary repair to delayed repair. In all three studies, the rate of recurrence was higher in group R than group S. When pooled, there was not a statistically significant difference between these groups, but there was a slightly higher odds of recurrence in group R (pooled OR 2.08, CI 0.69-6.26, p = 0.19). No significant differences were appreciated in functional outcomes or complications in these two groups.

CONCLUSION

Further level I and level II studies to compare surgical treatment after first time and recurrent instability are needed. This study failed to find a statistically significant difference in recurrence rates in patients who had stabilization acutely after a single episode compared to patients with recurrent instability events, although results suggest there may be a small benefit in primary stabilization.

Meta-Analysis of Randomized Controlled Trials Involving Anterior Shoulder Instability

Background:

Arthroscopic repair is gaining popularity over open repair for the treatment of bankart lesions. The study aims to evaluate the outcome of arthroscopic repair with open repair in randomised controlled trials conducted comparing the two techniques.

Methods:

We searched the Cochrane library, PubMed and EMBASE up to December 2017 for clinical trials comparing the outcomes of arthroscopic bankart repair with open bankart repair. We used fixed or random effects model depending upon heterogenicity. Dichotomous variables were presented as Risk Ratios (RRs) with 95% Confidence Intervals (CIs), and continuous data were measured as measured differences with 95% CIs.

Result:

Five studies were included, with sample size ranging from 42 to 196. Fixed effect analysis showed that the shoulder was more stable in open repair (RR=0.897, 95% CI: 0.821 to 0.980, P= 0.94) but the loss of external rotation at shoulder joint was also higher in those had open repair (RR=0.325, SMD=-0.411, 95% CI: -1.229 to 0.407). The functional outcome assessed by Rowe score was better in open repair (P=0.325). The operative time was lesser in arthroscopic repair but was not statistically significant (P=0.085).

Conclusion:

Our meta-analysis showed that the use of arthroscopic repair though offers better shoulder movement but the open repair is superior in terms of shoulder stability.

Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis

OBJECTIVE

To review and compare treatments (1) after primary traumatic shoulder dislocation aimed at minimising the risk of chronic shoulder instability and (2) for chronic post-traumatic shoulder instability.

DESIGN

Intervention systematic review with random effects network meta-analysis and direct comparison meta-analyses.

DATA SOURCES

Electronic databases (Ovid MEDLINE, Cochrane Clinical Trials Register, Cochrane Database of Systematic Reviews, Embase, Scopus, CINAHL, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, DARE, HTA, NHSEED, Web of Science) and reference lists were searched from inception to 15 January 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised trials comparing any interventions either after a first-time, traumatic shoulder dislocation or chronic post-traumatic shoulder instability, with a shoulder instability, function or quality of life outcome.

RESULTS

Twenty-two randomised controlled trials were included. There was moderate quality evidence suggesting that labrum repair reduced the risk of future shoulder dislocation (relative risk 0.15; 95% CI 0.03 to 0.8, p=0.026), and that with non-surgical management 47% of patients did not experience shoulder redislocation. Very low to low-quality evidence suggested no benefit of immobilisation in external rotation versus internal rotation. There was low-quality evidence that an open procedure was superior to arthroscopic surgery for preventing shoulder redislocations.

CONCLUSIONS

There was moderate-quality evidence that half of the patients managed with physiotherapy after a first-time traumatic shoulder dislocation did not experience recurrent shoulder dislocations. If chronic instability develops, surgery could be considered. There was no evidence regarding the effectiveness of surgical management for post-traumatic chronic shoulder instability.

Anterior Shoulder Instability: A Systematic Review of the Quality and Quantity of the Current Literature for Surgical Treatment

Background

Anterior shoulder instability is the most common sequela of shoulder dislocation and can result in repeated dislocations or subluxation of the glenohumeral joint. Anterior shoulder instability can be treated conservatively or surgically with several procedures.

Purpose

To date, arthroscopic Bankart is the most common surgical procedure for the treatment of anterior shoulder instability. No previous studies have compared all anterior shoulder surgical procedures. In this study, the authors performed a systematic review of journal articles describing all surgical procedures for anterior shoulder instability to determine the scientific evidence and level of recommendation.

Study Design

Systematic review; Level of evidence, 4.

Method

A comprehensive literature search was conducted (July 19, 2016) with 4 reputed databases: PubMed, EMBASE, the Cochrane databases, and Web of Science. The articles found in the literature search were screened by 2 reviewers on the basis of their titles, abstracts, and full text. Data were extracted from relevant studies, and potentially relevant records were selected for full-text review. Included articles were classified according to their scientific quality (level of evidence, 1-5). The studies were then combined for each surgical procedure, and a grade of recommendation was assigned for each procedure: grade A, treatment recommendation based on level 1 evidence studies; B, based on level 2 or 3 evidence studies; C, based on level 4 or 5 evidence and could represent conflicting results; or I, insufficient evidence to recommend a treatment. As such, the grade of recommendation provides a summary score for the quality and quantity of available literature to support the surgical procedures reviewed here.

Results

The systematic literature review generated 11,281 articles. After screening, 655 articles were included. Results revealed 31 surgical procedures for shoulder instability following dislocation: 10 surgical procedures were given an A or B recommendation; 11, a C recommendation; and 10, an I recommendation.

Conclusion

This review identified many surgical procedures to treat anterior shoulder instability. Ten of these surgical procedures had an abundant amount of published articles to describe their safety and efficacy. Arthroscopic Bankart and open Bankart were the most commonly reported procedures that cite satisfactory postoperative outcomes and limited complications. Publications on the other surgical procedures were less common. Surgeons should be careful when recommending surgery, and they should choose the appropriate surgical procedure based on evidence-based literature.

Can arthroscopic Bankart repairs using suture anchors restore equivalent stability to open repairs in the management of traumatic anterior shoulder dislocation? A meta-analysis

BACKGROUND

Recently, arthroscopic Bankart repairs have become much more popular than open repairs for the treatment of recurrent anterior shoulder instability. However, it is unclear whether the modern arthroscopic Bankart repairs using suture anchors could restore equivalent stability to open repairs. We conducted a meta-analysis to compare arthroscopic Bankart repairs using suture anchors and open repairs in regard to clinical outcomes.

METHODS

A literature review was performed according to the PRISMA guidelines. PubMed was searched from January 1966 to January 2017. Studies were identified using the terms 'anterior shoulder dislocation' or 'recurrent anterior shoulder dislocation' and 'Bankart repair'. The search yielded 36 publications. After reading the full-text articles, we included four randomized controlled trials and five retrospective studies that compared arthroscopic and open repairs using suture anchors.

RESULTS

No significant differences were found between the two procedures in frank re-dislocation and revision surgery due to recurrence. However, the overall recurrent instability including not only re-dislocation but also subluxation and apprehension was significantly higher in arthroscopic repairs than in open repairs, while a significantly higher Rowe score and lower loss of external rotation at 90° of abduction were observed following arthroscopic repairs compared to open repairs.

CONCLUSIONS

Modern arthroscopic Bankart repairs using suture anchors provide an equivalent outcome compared to open repairs in terms of apparent re-dislocation, but overall recurrent instability including subluxation or apprehension was still significantly higher in arthroscopic repairs than in open repairs.

An assessment of quality of randomized controlled trials in shoulder instability surgery using a modification of the clear CLEAR-NPT score

BACKGROUND

The present study aimed to evaluate the methodological quality and determine the quality of reporting of randomized controlled trials (RCTs) that assess surgical treatment for shoulder instability.

METHODS

A Cochrane, Pubmed, EMBASE and Trip database search was performed, including the relevant literature, regarding RCTs that report on shoulder instability published between January 1994 and January 2017. Methodological quality was assessed with a modification of the Checklist to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). Points were assigned based on 18 items regarding patient characteristics, randomization, care provider characteristics, surgical details and blinding, with a total score ranging from 0 points to 18 points. Missing items were verified with the corresponding authors of the studies. Quality of reporting corresponds to the total scores including the items that were additionally provided by the authors.

RESULTS

We included 22 studies. Of these, nine corresponding authors provided additional information. The average methodological quality was 16.9 points (11 studies) and the average quality of reporting was 9.5 points (22 studies). Items scoring worst included information regarding the surgeon's experience, the patients' level of activity, comorbidities, analyzing according to 'intention-to-treat' principles, and blinding of care providers, participants and assessors.

CONCLUSIONS

RCTs reporting on shoulder instability surgery are well performed but poorly reported.

Revisiting the Anterior Glenoid: An Analysis of the Calcified Cartilage Layer, Capsulolabral Complex, and Glenoid Bone Density

PURPOSE

In this cadaveric study, we aim to define the basic anatomy of the anterior glenoid with attention to the relationships of calcified cartilage, capsulolabral complex, and osseous morphology of the anterior glenoid.

METHODS

Seventeen cadaveric glenoid specimens (14 male, 3 female, mean age 53.9 ± 10) were imaged with micro-computed tomography (CT) and embedded in poly-methyl-methacrylate. Specimens were included for final analysis only if the entire glenoid articular cartilage, labrum, capsule, and biceps insertion were pristine and without evidence of injury, degeneration, or damage during the preparation process. Group 1 members (n = 9) were axially sectioned through 3 to 9 o'clock and 4 to 8 o'clock; group 2 members (n = 8) were radially sectioned through 3, 4, 5, and 9 o'clock. A scanning electron microscope (SEM) analysis quantified the percentage of bone within a 5 × 2.5 mm region at the glenoid rim. Micro-CT, SEM, and light microscopy evaluated the capsulolabral complex and calcified fibrocartilage.

RESULTS

A 7 ± 2.1 mm region of calcified fibrocartilage at 4 o'clock was identified from the articular face to the medial glenoid neck supporting the overlying capsulolabral footprint and was >3× thicker at the articular attachment (316 ± 153 μm) versus the glenoid neck (92 ± 66 μm). At 3 to 9 o'clock and 4 to 8 o'clock 79.2% ± 5.4% and 75.2% ± 7.8% of the glenoid osseous width was covered with articular cartilage. The labrum accounted for 13.1% ± 3.4% of the glenoid width at 4 o'clock. SEM analysis demonstrated decreased glenoid bone density at 3, 4, and 5 o'clock (P ≤ .015) and no difference (P = .448) at 9 o'clock versus central subchondral bone.

CONCLUSIONS

The capsulolabral footprint contributes significantly to the glenoid face, inserts directly adjacent to the articular cartilage, and extends medially along the glenoid neck. A layer of calcified fibrocartilage lies immediately beneath the capsulolabral footprint and is 3× thicker at the articular insertion compared with the glenoid neck. Lastly, there is a bone density gradient at the anterior-inferior rim versus the central subchondral bone.

CLINICAL RELEVANCE

Arthroscopic Bankart repair has been reported to have a significant failure rate in many settings. It is felt that reproducing anatomy with the repair could help improve outcomes. Based on this study's findings, an arthroscopic Bankart technique that most closely reproduces native anatomy and potentially optimizes soft-tissue healing could be performed. This includes removal of 1 to 2 mm of articular cartilage from the glenoid face with anchor placement at this location to appropriately reposition the capsulolabral complex.

Arthroscopic knotless anterior labral stabilization using labral tape and wide awake anaesthesia-short term results

BACKGROUND

The shoulder is the least constrained of all joints of the body and is more susceptible to injury including dislocation. The rate of recurrent instability following primary stabilization procedure at 10 years of follow-up ranged from 3.4 to 20%. There is a lack of evidence in the literature regarding use of labral tape and anchors for anterior stabilization despite the growing market for this product. We describe the outcomes of 67 patients who underwent knotless arthroscopic anterior stabilisation under awake anaesthesia using 1.5 mm LabralTape with 2.9 mm Pushlock anchors for primary anterior instability by a single surgeon.

METHODS

This was a retrospective analysis of prospectively collected outcome data for adult patients undergoing anterior stabilisation for primary traumatic anterior shoulder instability between 2013 and 2016 at two centres. Patients with > 25% glenoid bone loss, engaging Hill Sach's, and multidirectional instability were excluded. All cases underwent surgery using awake anaesthetic technique. The surgical technique and post-operative physiotherapy was standardized. Outcomes were measured at 6 months and 12 months.

RESULTS

Of the 74 patients in our study, 7 were lost to follow up. Outcomes were measured using the Oxford Instability Shoulder Score (OISS) and clinical assessment including the range of motion. The OISS showed statistically significant improvement from a mean score and standard deviation (SD) of 24.72 ± 2.8 pre-surgery to 43.09 ± 3.5 after the procedure at 12 months with good to excellent outcomes in 66 cases (98.5%). The mean abduction was 134.2 ± 6.32 and external rotation was 72.55 ± 5.42 at 60-90 position at 12 months. We report no failures due to knot slippage or anchor pull-out.

CONCLUSION

Our case series using the above technique has distinct advantages of combining a small non-absorbable implant with flat, braided, and high-strength polyethylene tape. This technique demonstrates superior medium term results to conventional suture knot techniques for labral stabilization thereby validating its use.

Return to sport following arthroscopic Bankart repair: a systematic review

HYPOTHESIS AND BACKGROUND

The purpose of this systematic review was to determine the return-to-sport rate following arthroscopic Bankart repair, and it was hypothesized that patients would experience a high rate of return to sport.

METHODS

The MEDLINE, Embase, and PubMed databases were searched by 2 reviewers, and the titles, abstracts, and full texts were screened independently. The inclusion criteria were English-language studies investigating arthroscopic Bankart repair in patients of all ages participating in sports at all levels with reported return-to-sport outcomes. A meta-analysis of proportions was used to combine the rate of return to sport using a random-effects model.

RESULTS

Overall, 34 studies met the inclusion criteria, with a mean follow-up time of 46 months (range, 3-138 months). The pooled rate of return to participation in any sport was 81% (95% confidence interval [CI], 74%-87%). In addition, the pooled rate of return to the preinjury level was 66% (95% CI, 57%-74%) (n = 1441). Moreover, the pooled rate of return to a competitive level of sport was 82% (95% CI, 79%-88%) (n = 273), while the pooled rate of return to the preinjury level of competitive sports was 88% (95% CI, 66%-99%).

CONCLUSION

Arthroscopic Bankart repair yields a high rate of return to sport, in addition to significant alleviation of pain and improved functional outcomes in the majority of patients. However, approximately one-third of athletes do not return to their preinjury level of sports.

Open Bankart repair plus inferior capsular shift versus arthroscopic Bankart repair without augmentations for traumatic anterior shoulder instability: A prospective study

PURPOSE

Arthroscopic treatment of shoulder instability has some advantages (including short surgical time, less morbidity, less postoperative pain, reduced hospitalization time, and decreased risk of complications) compared with open procedures. We performed a prospective study comparing open repair with arthroscopic repair for recurrent anterior shoulder instability. The aim was to clarify the relative effectiveness of open Bankart repair plus inferior capsular shift (OBRICS) and arthroscopic Bankart (AB) repair without augmentations with approximately 5 years of follow-up.

METHODS

We investigated 32 shoulders of 30 patients (24 men and 6 women) undergoing OBRICS (15 shoulders of 17 patients; two patients were bilateral) and AB (15 shoulders of 15 patients). The average follow-up was 5 years and 2.5 months (range: 60-66 months). The clinical evaluation included recurrent instability rate, range of motion, and postoperative rehabilitation. All patients were assessed using the scoring systems of Rowe and the University of California at Los Angeles (UCLA) preoperatively and during the final evaluation.

RESULTS

Recurrent instability rates were significantly different between the OBRICS (0%) and AB (26.6%) groups ( p = 0.022). There were fewer limitations of external rotation (ER), ER at 90° abduction, and horizontal extension for AB than for OBRICS postoperatively ( p < 0.05). The mean Rowe and UCLA scores for both methods were not significantly different at final follow-up.

CONCLUSION

Our data suggest that OBRICS leads to a lower rate of recurrent instability. However, those with AB had fewer ER and horizontal extension limitations.

Surgical stabilization for first-time shoulder dislocators: a multicenter analysis

BACKGROUND

Anterior shoulder dislocations in young patients are associated with high rates of recurrent instability. Although some surgeons advocate for surgical stabilization after a single dislocation event in this population, there is sparse research evaluating surgical treatment for first-time dislocators.

METHODS

Patients undergoing surgical stabilization for anterior shoulder instability were prospectively enrolled at multiple institutions from 2015-2017 and stratified by number of dislocations before surgery. Demographic data, preoperative patient-reported outcomes, imaging findings, surgical findings, and procedures performed were compared between groups. Analysis of variance, χ², and multivariate logistic regression were used for statistical analysis.

RESULTS

The study included 172 patients (mean age, 25.3 years; 79.1% male patients) for analysis (58 patients with 1 dislocation, 69 with 2-5 dislocations, 45 with >5 dislocations). There were no intergroup differences in demographic characteristics, preoperative patient-reported outcomes, or physical examination findings. Preoperative imaging revealed increased glenoid bone loss in patients with multiple dislocation events (P = .043). Intraoperatively, recurrent dislocators were more likely to have bony Bankart lesions (odds ratio [OR], 3.26; P = .024) and biceps pathology (OR, 6.27; P = .013). First-time dislocators more frequently underwent arthroscopic Bankart repair and/or capsular plication (OR, 2.22; P = .016), while recurrent dislocators were more likely to undergo open Bristow-Latarjet procedures (OR, 2.80; P = .049) and surgical treatment for biceps pathology (OR, 5.03; P = .032).

CONCLUSIONS

First-time shoulder dislocators who undergo stabilization are more likely to undergo an arthroscopic procedure and less likely to have bone loss or biceps pathology compared with recurrent dislocators. Future studies are needed to ascertain long-term outcomes of surgical stabilization based on preoperative dislocation events.

Functional outcome of arthroscopic double row repair for Bankart lesion

Introduction

The shoulder joint is the most common major joint to dislocate. Population aged younger than 20 years, recurrent dislocation rates have been reported to be as high as 90%. For those individuals that continue to experience dislocations surgery is often a good decision. The goal of the Bankart surgery is to reconnect the torn labrum to the glenoid fossa. Double-row Bankart repair can both achieve anatomic reduction and enhance fixation stability. The purpose of our study is to assess the clinical outcome of arthroscopic double row repair.

Methods

49 cases with Bankart lesion operated by double row repair were studied. Functional outcome and retear were assessed after at least 6 months of surgery using scores and MRI.

Results

Significant improvement in functional outcome after repair by double row Bankart repair. No retear or redislocation seen.

Conclusion

Double row repair technique improves function of shoulder significantly and potentially minimizes future re-injury or recurrence risk.

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.