Restoring the labral height for treatment of Bankart lesions: a comparison of suture anchor constructs

Arthroscopic Posterior Capsulolabral Repair With Suture-First Versus Anchor-First Technique in Patients With Posterior Shoulder Instability (Type B2): Clinical Midterm Follow-up

Background

Isolated soft tissue injuries of the posterior capsulolabral complex can be addressed arthroscopically, with various anchor systems available for repair.

Purpose

To evaluate clinical and patient-reported outcomes after arthroscopic capsulolabral repair in patients with posterior shoulder instability (PSI) and to compare differences in outcomes between patients treated with a suture-first technique (PushLock anchor) and an anchor-first technique (FiberTak all-suture anchor).

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 32 patients with dynamic structural PSI (type B2 according to the ABC classification) treated with an arthroscopic posterior capsulolabral repair. After a mean follow-up time of 4.8 ± 3.4 years (range, 2-11) patients were evaluated clinically, and standardized outcome scores were obtained for the Subjective Shoulder Value (SSV), the Western Ontario Shoulder Instability Index (WOSI), Rowe, Kerlan-Jobe Orthopaedic Clinic (KJOC), patient satisfaction (0-5 [best]), and pain on a visual analog scale (VAS; 0-10 [worst]).

Results

The overall satisfaction level with the outcome of the surgery was 4.6 ± 0.5 (range, 4-5). No patient suffered from instability events. The mean VAS level for pain was 0.4 ± 0.9 (range, 0-4) at rest and 1.9 ± 2.0 (range, 0-6) during motion. The mean SSV was 80 ± 17 (range, 30-100), the mean postoperative WOSI score 75% ± 19% (range, 18-98), the mean Rowe score 78 ± 20 (range, 10-100), and the mean KJOC score was 81 ± 18 (range, 40-100) for the entire cohort. There was no significant difference between the techniques with regard to range of motion, strength, or clinical outcome scores.

Conclusion

Arthroscopic posterior capsulolabral repair was a satisfactory method to treat structural PSI type B2 with regard to stability, pain relief, and functional restoration. The majority of patients had good outcomes. No differences in outcomes were observed between the anchor-first and suture-first techniques.

Ability to Retension Knotless Suture Anchors: A Biomechanical Analysis of Simulated Bankart Lesions

Background:

Knotless suture anchors are gaining popularity in arthroscopic glenohumeral labral repairs. The ability to retension knotless designs after initial anchor placement has been reported; however, no studies have quantified this claim or investigated the biomechanical consequence of retensioning.

Purpose/Hypothesis:

To determine whether knotless and knotted suture anchors have biomechanical or anatomic differences with regard to labral repairs and to determine whether retensioning of knotless suture anchors affects capsular tension, labral height, and capsular shift. We hypothesized that retensioning of knotless anchors would result in improved capsular tension compared with conventional knotted suture anchors.

Study Design:

Controlled laboratory study.

Methods:

A total of 18 fresh-frozen cadaveric shoulders with a mean age of 56 years were dissected to the capsule and disarticulated at the humeral capsular insertion. The scapula was potted and placed in a custom shoulder simulator to tension the capsule via braided sutures localized to the anteroinferior glenohumeral ligament. Specimens were randomized into 3 groups: (1) Knotted (KT), (2) Knotless with end retensioning (KL_end), and (3) Knotless with stepwise retensioning (KL_stepwise). All repairs were completed using all-suture anchors placed at the 5-, 4-, and 3-o’clock positions. KL_stepwise was used to simulate an intraoperative technique. Resultant mean capsular tension under 5 mm of displacement (subfailure loading) was measured for each anchor placement and retensioning step. Labral height and capsular shift were measured using a MicroScribe digitizer.

Results:

The intact, defect, 1-anchor, 2-anchor, and 3-anchor tensions were not significantly different between the KT and KL_end groups. For the latter, retensioning of all knotless anchors increased capsular tension by 2.1 N compared with its 3-anchor state, although this was not statistically significant (P = .081). The KL_stepwise group explored an alternative method to retension the capsule using knotless anchors, with similar final capsular tensions compared with the other groups. All repairs had similar improvements in capsulolabral height and superior capsular shift.

Conclusion:

Knotted and knotless suture anchors provided similar overall restorations in anteroinferior glenohumeral ligament tension. However, knotless devices were capable of small but statistically insignificant improvements in capsular tension with retensioning.

Clinical Relevance:

Retensioning of knotless anchors allows the surgeon to tighten regions of the glenohumeral capsule that remain lax after repair.

Knotless PEEK and double-loaded biodegradable suture anchors ensure comparable clinical outcomes in the arthroscopic treatment of traumatic anterior shoulder instability: a prospective randomized study

PURPOSE

To compare the clinical outcome of arthroscopic capsulolabral repair for traumatic anterior shoulder instability with PEEK knotless and knotted biodegradable suture anchors.

METHODS

Arthroscopic stabilization was performed in 78 patients with recurrent traumatic anterior shoulder instability. They were divided into 2 groups of 39 patients each, according to suture anchors used: knotless PEEK anchors in group 1, and biodegradable anchors in group 2. Exclusion criteria were: instability without dislocation, posterior or multidirectional instability, glenoid bone loss > 20%, off-track lesions, concomitant rotator cuff tears and previous surgery. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) self-administered questionnaire. Secondary outcomes were: Work-DASH, Sport-DASH, Rowe score, recurrent instability and subsequent surgery. The following independent variables were considered: age, gender, dominance, generalized ligamentous hyperlaxity, duration of symptoms, age at first dislocation, number of dislocations, type of work, type of sport, sports activity level, capsule-labral injury pattern, SLAP lesion and number of anchors. Differences between groups for numerical variables were analyzed by use of the Student's t-test or Mann-Whitney U-test. Fisher's exact test was used for analysis of categorical variables. Significance was set at p < 0.05.

RESULTS

Seven patients (9%) were lost at follow-up, 5 from group 1 and 2 from group 2. Follow-up ranged from 36 to 60 months (median: 44; IQR: 13). Comparison between groups did not show significant differences for each independent variable considered. No differences could be found either for DASH (n.s.) or Rowe (p = n.s.) scores between the two groups. Overall recurrence rate was 7%. Three re-dislocations were reported in group 1 and two in group 2 (n.s.). Only one patient in each group underwent re-operation.

CONCLUSIONS

The study showed no significant differences in clinical outcomes after arthroscopic treatment of traumatic anterior shoulder instability using PEEK knotless or biodegradable knotted anchors at mid-term follow-up.

LEVEL OF EVIDENCE

I.

Current concepts in anterior glenohumeral instability: diagnosis and treatment

The glenohumeral joint is the most dislocated articulation, accounting for more than 50% of all joint dislocations. The reason behind shoulder instability should be investigated in detail for successful management, and the treatment plan should be individualized for all patients. Several classification systems have been proposed for glenohumeral instability. A physical exam is mandatory no matter what classification system is used. When treating patients with anterior shoulder instability, surgeons need to be aware of the critical size of the bone loss, which is commonly seen. The glenoid track concept was clinically adopted, and the measurement of the glenoid track for surgical decision-making is recommended. Detailed assessment of existing soft tissue injury to the labrum, capsule, glenohumeral ligaments, and rotator cuff is also mandatory as their presence influences the surgical outcome. Rehabilitation, arthroscopic repair techniques, open Bankart procedure, capsular plication, remplissage, Latarjet technique, iliac crest, and other bone grafts offer the surgeon different treatment options according to the type of patient and the lesions to be treated. Three-dimensional (3D) technologies can help to evaluate glenoid and humeral defects. Patient-specific guides are low-cost surgical instruments and can be used in shoulder instability surgery. 3D printing will undoubtedly become an essential tool to achieve the best results in glenohumeral instability surgery.

Knotted Versus Knotless Anchors for Labral Repair in the Shoulder: A Systematic Review

PURPOSE

To compare biomechanical and clinical outcomes between knotless and knotted anchors in arthroscopic labral repair, specifically in (1) Bankart repair, (2) SLAP repair, (3) posterior labral repair, and (4) remplissage augmentation of Bankart repair.

METHODS

MEDLINE, EMBASE, and the Cochrane Library were searched according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to find biomechanical and clinical studies comparing knotted and knotless anchors using the search term "knotless anchor."

RESULTS

Overall, 17 studies met inclusion criteria. There were 7 studies evaluating the biomechanical outcomes, of which 5 found mixed results between knotted and knotless anchors for arthroscopic Bankart repair, 1 demonstrated a difference for SLAP repair favoring knotless anchors, and 2 showed no significant difference for Remplissage in terms of ultimate load-to-failure. Four studies evaluated knotless labral anchors compared with knotted anchors in patients undergoing arthroscopic Bankart repair with no significant differences in outcomes reported between the 2 anchor types, except in one study that found an improved visual analog scale score and a lower recurrence and revision rate with knotted anchors. Five studies evaluated knotless anchors compared with knotted anchors in patients undergoing SLAP repair, and none of the included studies found any significant differences in the patient reported outcome measures or revision rates. Of the 5 studies comparing operative time, 4 found a reduced time with knotless anchors.

CONCLUSIONS

The clinical results show no significant differences in outcomes between knotless and knotted anchors for labral repair in the shoulder, including Bankart repair, SLAP repair, and posterior labral repair. However, there was conflicting evidence supporting knotless or knotted anchors in the biomechanical studies. However, operative times may be reduced with the use of knotless anchors.

LEVEL OF EVIDENCE

III, A Systematic Review of Level II and III studies.

Comparison between all-suture and biocomposite anchors in the arthroscopic treatment of traumatic anterior shoulder instability: A retrospective cohort study

Purpose

Suture anchors have revolutionized arthroscopic surgery, enabling direct soft tissue-to-bone repair. There are many types of anchors still used in arthroscopic shoulder operations. We sought to compare the clinical outcome of all-suture and biocomposite anchors when used in arthroscopic Bankart repair for patients suffering from anterior shoulder instability.

Methods

A single-center retrospective cohort study of 30 patients (mean age: 26.6 years, SD: 8.8 years, male/female ratio: 5/1, mean follow up: 28 months, SD: 23.8, range: 12-92) with anterior shoulder instability was conducted. Patients were divided into 2 groups based upon the type of suture anchors used for the Bankart repair: group A (14 patients) used only all-suture anchors and group B (16 patients) used only biocomposite anchors. Outcomes reported were postoperative dislocations, positive shoulder apprehension test, self-reported sense of shoulder instability, return to activities of daily living, return to sports, patient satisfaction and complications. Patient reported outcome measures (PROMs) used were the Rowe Score for Instability, Constant Shoulder Score, Walch Duplay Score, The American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Oxford Shoulder Instability Score and external rotation at 90° of arm abduction, external rotation at 0° of arm abduction, forward flexion, abduction, adduction and internal rotation.

Results

Rates of postoperative shoulder dislocation demonstrated no significant difference between the 2 groups (p > .05). Four postoperative dislocations happened, two in each group (14.3% and 12.5% for all suture only and biocomposite only groups, respectively), with three of them being traumatic. In addition, no significant differences were observed amongst groups regarding shoulder apprehension test (group A: 85.7% vs. group B: 93.8%), sense of shoulder instability (7.1% vs. 6.3%), return to activities of daily living (group A: 85.7% vs. group B: 93.8%), return to sports (group A: 85.7% vs. group B: 87.5%), patient satisfaction (moderate level: group A 21.4% vs. group B 12.5%), and PROMs.

Conclusion

The short-term failure rate and clinical/functional outcomes of arthroscopic Bankart repair using all-suture anchors is similar to the use of biocompatible anchors.

Level of evidence

Level III, retrospective cohort study.

Serial Changes in Perianchor Cysts Following Arthroscopic Labral Repair Using All-Suture Anchors

Backgroud

Changes in perianchor cysts around the all-suture anchors, which demonstrate distinguished features from the biocomposite anchors, have not been revealed sufficiently. The purpose of this study was to investigate serial changes of perianchor cysts according to the location of the inserted anchor in the glenoid in arthroscopic labral repair using all-suture anchors.

Methods

We enrolled 43 patients who underwent computed tomography (CT) immediately postoperatively and CT arthrogram (CTA) at 1 year or 2 years after arthroscopic labral repair using a 1.3-mm all-suture anchor for recurrent anterior shoulder dislocation with or without a superior labral tear from anterior to posterior and a posterior labral tear. The mean diameter and tissue density (HU) of perianchor cysts were measured depending on the location in the glenoid. Clinical outcomes, labral healing, and redislocation rate were evaluated at 2 years after surgery.

Results

On functional assessment, the mean American Shoulder and Elbow Surgeons score and Rowe score improved statistically significantly after surgery (from 47.9 ± 14.3 preoperatively to 90.1 ± 9.6 postoperatively and from 45.3 ± 12.4 preoperatively to 92.2 ± 10.1 postoperatively, respectively; p < 0.01). Postoperative redislocations were found in 2 patients (4.7%). In radiological evaluation, the mean diameter of perianchor cysts at postoperative 1 year (3.24 ± 0.65 mm) was significantly larger than the immediate postoperative diameter; however, there was no significant difference between postoperative 1 year and 2 years (3.23 ± 0.57 mm). Tissue density at the center of cysts demonstrated no significant difference between 1 and 2 year postoperatively (107.7 ± 29.8 HU [superior], 99.7 ± 31.7 HU [anteroinferior], and 105.1 ± 25.0 HU [posterior] vs. 109.1 ± 26.1 HU [superior], 106.4 ± 30.3 HU [anteroinferior], and 111.0 ± 32.9 HU [posterior]). The mean diameter of perianchor cysts in the anteroinferior position was largest compared with that in superior or posterior positions.

Conclusions

Perianchor cysts associated with all-suture anchors enlarged significantly within 1 year after arthroscopic labral repair regardless of the insertion location in the glenoid. However, the size and tissue density of perianchor cysts were similar at postoperative 1 and 2 years, and satisfactory stability and clinical outcomes were obtained.

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.

Inter-surgeon variability in the identification of clock face landmarks when placing suture anchors in arthroscopic Bankart repair

BACKGROUND

The accuracy of surgeons in utilizing the clock face method for anchor placement has never been investigated. Our hypothesis was that shoulder arthroscopy surgeons would be able to place suture anchors at predetermined positions with accuracy and reliability.

METHODS

Ten cadaveric shoulders were used. Five fellowship-trained shoulder arthroscopy surgeons were directed to place a suture anchor at 3:30, 4:30, and 5:30 clock in two shoulders each. The position of the anchors was determined with computed tomography. The accuracy of placement was calculated and data analyzed with one-way analysis of variance. The intraclass correlation coefficients were calculated.

RESULTS

The overall accuracy was 57%. The accuracy of anchor placement at the 3:30 position was 40% (average position 2:24 o'clock), it was 50% at the 4:30 position (average position 3:42 o'clock) and 80% at the 5:30 position (average position 5:03 o'clock). No statistical difference in accuracy between the placement of the superior, middle, and inferior anchors (p = 0.145) was seen. The intraclass correlation coefficient for inter-surgeon reliability was 0.4 (fair) while the intraclass correlation coefficient for intra-surgeon reliability was 0.6 (moderate).

DISCUSSION

The findings of this study suggest a moderate degree of accuracy and fair to moderate inter- and intra-surgeon reliability when using the clock face system to guide anchor placement.

Bankart lesion repair: biomechanical and anatomical analysis of Mason-Allen and simple sutures in a swine model

Objective

To evaluate the labral height and pullout resistance after the repair of Bankart lesions in the glenohumeral joint of swine models, using double-loaded anchors with two suture configurations: simple and Mason-Allen.

Methods

Ten swine shoulders were used, in which Bankart lesions were created. For each specimen, the lesion was sutured randomly with Mason-Allen sutures or simple sutures. The labral height was measured before the lesion was created and after the labral repair. The specimens were submitted to a tensile test for biomechanical evaluation.

Results

In specimens submitted to simple suture (n = 5), the mean labral height observed before the lesion was 3.86 mm, and after suturing, 3.33 mm. In specimens submitted to Mason-Allen suture (n = 5), it was observed that the mean labral height before the lesion was 3.92 mm, and after suturing, 3.48 mm. When comparing the labral height after simple suture and Mason-Allen suture, no significant difference was observed. The pullout force at the end of the tensile test on specimens with single suture was 130 N, and in specimens with Mason-Allen suture, 128.6 N. No statistically significant differences were observed between the shoulders treated with single suture and Mason-Allen suture; p = 0.885.

Conclusions

Repair of Bankart lesions with Mason-Allen suture provides increased labrum height; however, it does not increase the pullout strength.

The "Purse String" Procedure for Recurrent Anterior Glenohumeral Instability: A Simple Technique to Achieve Bankart Repair, Capsular Shift, and a Good Labral Bumper

Failure of arthroscopic techniques in cases of recurrent anterior glenohumeral instability may result from inadequate treatment of capsular injury. The use of few anchors has been cited as a cause of failure in arthroscopic stabilization techniques. This applies to the use of the suture anchors as spot-welding points in conventional techniques. It has been shown that horizontal mattress suture techniques restore better labral height and anatomy than simple suture techniques in the repair of acute Bankart lesions. Horizontal mattress repairs, like the one achieved with the "purse-string" technique, pushes the labrum toward the humeral side of the joint, thus providing a buttress to the glenohumeral joint. We present the purse-string technique, which involves the use of only 1 suture anchor located at the 4-o'clock position. Sutures are passed through the labrum and capsule from south to north, thus allowing the incorporation of more capsular tissue involved in the raising of the anterior labral bumper. One suture anchor at the 4-o'clock position is used to ensure a purse-string effect, with tightening of the capsule in the inferosuperior plane and repair of the Bankart lesion. The repair achieved is 3-fold: Bankart repair, south-to-north capsular shift, and creation of an anterior bumper.

Arthroscopic Knotless Repair of the Posterior Labrum Using LabralTape

Operative management of symptomatic labral tears of the shoulder has traditionally been the preferred treatment. Arthroscopic techniques and equipment continue to be refined and subsequent new recommendations for treatment are being developed. Contemporary techniques for arthroscopic knotless repair offer possible advantages over traditional arthroscopically tied knots. Although knotless repair of labral tears is well recognized, advancements continue to progress toward stronger fixation with reduced risks of cutting through the labrum and chondral abrasion. The suture tape used in the technique presented for arthroscopic knotless repair is stronger and flatter than traditional rounded suture and offers many potential benefits.

Triple labrum tears repaired with the JuggerKnot™ soft anchor: Technique and results

Purpose:

The 2-year outcomes of patients undergoing repair of triple labrum tears using an all-suture anchor device were assessed.

Materials and Methods:

Eighteen patients (17 male, one female; mean age 36.4 years, range: 14.2-62.3 years) with triple labrum tears underwent arthroscopic repair using the 1.4 mm JuggerKnot Soft Anchor (mean number of anchors 11.5, range: 9-19 anchors). Five patients had prior surgeries performed on their operative shoulder. Patients were followed for a mean of 2.0 years (range: 1.6-3.0 years). Constant–Murley shoulder score (CS) and Flexilevel scale of shoulder function (FLEX-SF) scores were measured, with preoperative and final postoperative mean scores compared with a paired Student's t-test (P < 0.05). Magnetic resonance imaging (MRI) was also performed at final postoperative.

Results:

Overall total CS and FLEX-SF scores increased from 52.9 ± 20.4 to 84.3 ± 10.7 (P < 0.0001) and from 29.3 ± 4.7 to 42.0 ± 7.3 (P < 0.0001), respectively. When divided into two groups by whether or not glenohumeral arthrosis was present at the time of surgery (n = 9 each group), significant improvements in CS and FLEX-SF were obtained for both groups (P < 0.0015). There were no intraoperative complications. All patients, including contact athletes, returned to their preinjury level of sports activity and were satisfied. MRI evaluation revealed no instances of subchondral cyst formation or tunnel expansion. Anchor tracts appeared to heal with fibrous tissue, complete bony healing, or combined fibro-osseous healing.

Conclusion:

Our results are encouraging, demonstrating a consistent healing of the anchor tunnels through arthroscopic treatment of complex labrum lesions with a completely suture-based implant. It further demonstrates a meaningful improvement in patient outcomes, a predictable return to activity, and a high rate of patient satisfaction.

Level of Evidence:

Level IV case series.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Biomechanical evaluation of knotless anterior and posterior Bankart repairs

PURPOSE

The value of modern tape-like suture materials and the influence of the number of anchors inserted for arthroscopic Bankart repairs compared to the intact state have yet to be investigated. It was hypothesised: (1) suture-tape repairs will show higher biomechanical strength than common suture repairs, (2) four anchors will be stronger than three, and (3) the strength of the native capsulolabral complex will be greater than repairs.

METHODS

Six matched-paired cadaveric shoulders received Bankart lesions/reconstructions and three underwent intact state testing. Anteroinferior repairs compared suture and suture-tape repairs using three anchors, while posteroinferior repairs compared three and four suture anchors using common sutures. An established testing protocol was run for biomechanical testing.

RESULTS

There was no significant difference in the maximum loads, loads at 2 mm displacement, stiffness or energy between repair groups or between repairs and the intact state (n.s.). However, failure modes were different: 16/24 (66.7%) of the repair groups showed glenoid labrum detachment compared to 2/12 (16.7%) within the intact state group (P = 0.012).

CONCLUSIONS

While biomechanical parameters of repairs and intact states showed equivalence, failure-mode analysis reaffirms previous findings that capsulolabrum complex refixation is weaker than the native attachment. Therefore, in daily clinical practice, type of suture is secondary and insertion of a fourth anchor will be unlikely to add strength but may confer additional risk and cost.

Restoration of joint congruency and the glenoidal labrum after arthroscopic revision Bankart repair: a MRI match-paired analysis comparing primary Bankart repair and the uninjured labrum

PURPOSE

The restoration of joint congruency and labrum slope and height after arthroscopic revision Bankart repair (RB) compared to the primary arthroscopic Bankart repair (PB) remain unclear.

METHODS

Twenty-three consecutive patients after RB with minor glenoid deficits were matched to 23 patients after PB and retrospectively followed by a score system and native 1.5 T magnetic resonance imaging (MRI) assessment. Bankart repair surgeries were performed using double-loaded knotless suture anchors. The glenoidal (GAA) and labral articulation arc (LAA), labrum slope, height index and morphology were assessed separately for the anterior and inferior glenoid and compared to 23 healthy volunteers [radiologic control group (RC)].

RESULTS

Arthroscopic revision Bankart repair showed 28.0 months post-operative equivalent anterior labral congruency (LAA, 9.3°/PB 9.9°/RC 10.1°) and inferior (LAA 9.9°/PB 9.6°/RC 10.5°). The anterior GAA remain decreased (54.6°/PB 55.7°/RC 58.0°) with an original inferior GAA (85.1°/PB 83.2°/RC 83.8°). The RB labrum was slightly decreased anteriorly (slope 22.9°/PB 23.9°/RC 24.6°; height index 2.4/PB 3.0/RC 3.2). The inferior portion had an equivalent labrum slope (23.8°/PB 24.7°/RC 25.1°), but a decreased height index (2.1/PB 2.2/RC 2.3). Morphologic labrum analysis revealed significant changes between all three groups. The clinical outcome after revision surgery was good-to-excellent, but inferior to the primary stabilization and without influence of joint congruency and labrum morphology to the clinical outcome.

CONCLUSION

A properly applied arthroscopic revision of a Bankart repair generates sufficient restoration of the anteroinferior labral joint congruency and good clinical results.

STUDY DESIGN

Case series.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Movement-induced knot migration after anterior stabilization in the shoulder

PURPOSE

This study compared the status of suture knots immediately after repair and after shoulder motion to evaluate the possibility of movement-induced knot migration to a location nearer the glenoid.

METHODS

We included 10 shoulders from 5 cadavers in the study. After posterior capsulotomy, a Bankart lesion was created. A capsulolabral repair was then performed with 3 knot-tying suture anchors. All knots were positioned on the capsular side, far from the articular surface. After the repair was complete, a photograph was taken with a metal rod placed to reference absolute distance. After passive pendulum motion was applied, another photograph was taken. The length of the suture strand from the knot base to the anchor insertion site was measured during both the initial repair and post-motion periods.

RESULTS

Initial distances were 4.83 ± 1.09 mm for the inferior knot, 4.70 ± 0.97 mm for the middle knot, and 3.84 ± 1.25 mm for the superior knot. After motion, the distances were 3.52 ± 1.21 mm (P = .01), 3.07 ± 0.81 mm (P < .001), and 2.69 ± 1.18 mm (P = .016), respectively. Additional observations showed changes in direction and security of the knot. The change in knot direction from an initial orientation facing the capsular side to a new orientation facing the glenoid was observed in 5 of 10 inferior, 7 of 10 middle, and 6 of 10 superior knots. In addition, knot loosening was noted for the last half-hitches in 4 inferior knots and 1 middle knot.

CONCLUSIONS

Intentional placement of suture knots away from the joint surface was not maintained after motion at the shoulder.

CLINICAL RELEVANCE

Movement-induced knot migration may be detrimental to articular cartilage in the event that a knot becomes interposed between the glenoid and humeral head.

Simple versus horizontal suture anchor repair of Bankart lesions: which better restores labral anatomy?

PURPOSE

The goal of this study was to determine which suture repair technique better restores glenoid labrum height: horizontal sutures or simple sutures.

METHODS

Sixteen cadaveric glenoids, 8 per repair technique, were used to measure native labral height at the 3:00 to 6:00 positions in half-hour increments. A Bankart lesion was then created from 3:00 to 6:30. Height measurements at each time point were again taken after creation of the Bankart lesion. Repair with a 3-mm knotted suture anchor was then performed at 3:30, 4:30, and 5:30 with either a simple or horizontal suture technique, and postrepair heights were measured across all time points.

RESULTS

Significant decreases in height, as compared with native height, were observed at 3:30, 4:30, and 5:30 in the simple repair group. Decreases in height of 1.4 mm (P = .044), 2.1 mm (P = .030), and 1.1 (P = .034) were observed at 3:30, 4:30, and 5:30. There was no significant decrease in height at these respective time points in the horizontal repair group.

CONCLUSIONS

The in vitro horizontal mattress suture technique better restores labral height and anatomy when compared with a simple suture technique in the repair of acute Bankart lesions.

CLINICAL RELEVANCE

Compared with the simple suture technique, horizontal suture repair may provide increased stability to the glenohumeral construct.

Change in labrum height after arthroscopic Bankart repair: correlation with preoperative tissue quality and clinical outcome

HYPOTHESIS

Arthroscopic factors, such as labral and capsular tissue quality or anterior labral periosteal sleeve avulsion (ALPSA) lesion, affect postoperative labral height stability. Labral height stability has a correlation with clinical outcome.

METHODS

The study included 40 patients who underwent arthroscopic surgery for a Bankart lesion between August 2005 and May 2009. The mean follow-up and patient age were 29.1 ± 10.9 months (range, 15-60 months) and 24.7 ± 8.4 years (range, 12-55 years), respectively. Labral and capsular tissue quality, ALPSA lesions, Hill-Sachs lesions, glenoid erosion, and superior labrum anterior-posterior tears were identified by arthroscopic examination. Stepwise postoperative computed tomography arthrography to estimate the labral height was performed at 3 months and 1 year.

RESULTS

Correlation of postoperative 1 year Rowe scores with labral height maintenance was statistically significant (P < .01). Correlation of Rowe scores at 1 year postoperatively with labral height at 1 year postoperatively was also statistically significant (P < .01). The mean postoperative labral height at 3 months and at 1 year was 5.13 ± 1.56 mm (range, 2.9-8.8 mm) and 4.69 ± 1.75 mm (range, 1.6-8.5 mm), respectively (P < .01). The decrease in labral height at 1 year after surgery was significant in those patients with ALPSA lesions, Hill-Sachs lesions, and a poor labrum along with a poor capsule (P < .01).

CONCLUSIONS

The patients with less labral height decrease between 3 months and 1 year or higher labral height at 1 year postoperatively showed higher Rowe scores at 1 year postoperatively. Shoulders with ALPSA lesions, Hill-Sachs lesions, and a poor labrum with poor capsular tissue quality correlated more strongly with postoperative labral height decrease.

Restoration of labral anatomy and biomechanics after superior labral anterior-posterior repair: comparison of mattress versus simple technique

BACKGROUND

Both simple and mattress repair techniques have been utilized with success for type II superior labral anterior-posterior (SLAP) lesions; however, direct anatomic and biomechanical comparisons of these techniques have yet to be clearly demonstrated.

HYPOTHESIS

For type II SLAP lesions, the mattress suture repair technique will result in greater labral height and better position on the glenoid face and exhibit stronger biomechanical characteristics, when cyclically loaded and loaded to failure through the biceps, compared with the simple suture repair technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Six matched pairs of cadaveric shoulders were dissected, and a clock face was created on the glenoid from 9 o'clock (posterior) to 3 o'clock (anterior). For the intact specimen, labral height and labral distance from the glenoid edge were measured using a MicroScribe. A SLAP lesion was then created from 10 o'clock to 2 o'clock. Lesions were repaired with two 3.0-mm BioSuture-Tak anchors placed at 11 o'clock and 1 o'clock. For each pair, a mattress repair was used for one shoulder, and a simple repair was used for the contralateral shoulder. After repair, labral height and labral distance from the glenoid edge were again measured. The specimens were then cyclically loaded and loaded to failure through the biceps using an Instron machine. A paired t test was used for statistical analysis.

RESULTS

After mattress repair, a significant increase in labral height occurred compared with intact from 2.5 ± 0.3 mm to 4.3 ± 0.3 mm at 11 o'clock (P = .013), 2.7 ± 0.5 mm to 4.2 ± 0.7 mm at 12:30 o'clock (P = .007), 3.1 ± 0.5 mm to 4.2 ± 0.7 mm at 1 o'clock (P = .006), and 2.8 ± 0.7 mm to 3.7 ± 0.8 mm at 1:30 o'clock (P = .037). There was no significant difference in labral height between the intact condition and after simple repair at any clock face position. Labral height was significantly increased in the mattress repairs compared with simple repairs at 11 o'clock (mean difference, 2.0 mm; P = .008) and 12:30 o'clock (mean difference, 1.3 mm; P = .044). Labral distance from the glenoid edge was not significantly different between techniques. No difference was observed between the mattress and simple repair techniques for all biomechanical parameters, except the simple technique had a higher load and energy absorbed at 2-mm displacement.

CONCLUSION

The mattress technique created a greater labral height while maintaining similar biomechanical characteristics compared with the simple repair, with the exception of load and energy absorbed at 2-mm displacement, which was increased for the simple technique.

CLINICAL RELEVANCE

Mattress repair for type II SLAP lesions creates a higher labral bumper compared with simple repairs, while both techniques resulted in similar biomechanical characteristics.

MRI assessment of the structural labrum integrity after Bankart repair using knotless bio-anchors

PURPOSE

Adequate labral restorations after Bankart repair have been demonstrated in cadaver models for knot-tying and knotless anchors and in vivo by magnetic resonance imaging for knot tying. The influence of glenoidal bio-degradation on clinical outcome, and conclusions regarding drill hole enlargement and foreign body reactions remain controversial.

METHODS

The labrum was analyzed in magnetic resonance images for 37 consecutive patients with Bankart repair using knotless PLLA anchors and for 31 volunteers as radiologic controls. The labrum was assessed regarding slope, height index (quotient between labral height to the glenoid height), and labrum morphology in axial and coronal T2 images. Glenoidal bio-degradation was graded in terms of the drill hole configuration in T1 images and the corresponding osseous reaction in T2 images. Constant-Murley, Walch-Duplay, and Rowe scoring were carried out preoperatively and at follow-up.

RESULTS

At 15 months after arthroscopy, the anterior slope (24.8°), height index (3.0), inferior slope (25.4°), and height index (2.5) were not significantly different from control values. Morphologic analysis revealed significant changes in the Bankart group (P < 0.05) that were influenced by the number of preoperative dislocations. Bio-degradation proceeded slowly with no evidence of drill hole enlargement. Osseous reactions were significantly greater in inferior compared to superior implants. The clinical scores were excellent and were not influenced by bio-degradation.

CONCLUSIONS

Knotless anchors facilitate labral restoration that is comparable to the knot-tying approach. Bio-degradation proceeds slowly without clinical or radiologic evidence of foreign body reactions.

LEVEL OF EVIDENCE

III.

Freehand versus navigated glenoid anchor positioning in anterior labral repair

PURPOSE

Anchor placement on the glenoid rim is challenging with the angle of insertion critical to achieving satisfactory results. Incorrect anchor placement is a common problem.

METHODS

Three plastic shoulder models were used. Reference markers were attached in the posterior portion of the acromion. Using the navigation system, reference point data from the glenoid were acquired. An anterior labral lesion of the glenoid was created that extended from the 1 o'clock to the 5 o'clock position. Three suture anchors were placed under arthroscopic guidance without the aid of navigation system (Group A) and with the aid of navigation system (Group B). Deviation from the optimal angle of 45° for anchor placement was measured and compared between the two groups.

RESULTS

The mean insertion angles for anchor placement were 45.9° (SD 3.4°, 40.2°-50.4°) and 41.4° (SD 3.9°, 33.1°-47.6°) in the freehand (Group A) and navigated (Group B) groups, respectively. There was a statistically significant difference between the groups (P < 0.05). The mean deviation (from the optimal angle) was 4.2° (SD 3.2°, 0.0°-11.9°) and 2.8° (SD 2.2°, 0.2°-8.4°) in the freehand and navigated groups, respectively.

CONCLUSION

Navigation systems may improve the accuracy of glenoid anchor placement amongst low-volume shoulder surgeons. However, it does not provide any significant advantage over the freehand technique in a plastic shoulder model. Constant multiplanar visualization throughout anchor placement as facilitated by navigation made the procedure more manageable, even for an experienced surgeon.

Long term results of arthroscopic Bankart repair for traumatic anterior shoulder instability

Background

The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. We would like to report the 2 year clinical outcomes of bio-absorbable suture anchors used in traumatic anterior dislocations of the shoulder.

Methods

Data from 79 shoulders in 74 patients were collected over 4 years (2004 - 2008). Each patient was followed-up over a period of 2 years. The patients underwent arthroscopic Bankart repair using bio-absorbable suture anchors for their shoulder instability. These surgeries were performed at a single institution by a single surgeon over the time period. The patients were assessed with two different outcome measurement tools. The University of California at Los Angeles (UCLA) shoulder rating scale and the Simple Shoulder Test (SST) score. The scores were calculated before surgery and at the 2-year follow-up. The recurrence rates, range of motion as well post-operative function and return to sporting activities were evaluated.

Results

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

Conclusion

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