Bankart augmentation for capsulolabral deficiency using a split subscapularis tendon flap

Transglenoid Fixation Technique for Arthroscopic Subscapularis Augmentation Using an Adjustable-Length Loop Cortical Suspensory Fixation Device

The optimal surgical management of anterior shoulder instability remains controversial. Although it has low recurrence rates and good clinical results, the Latarjet procedure has some disadvantages and is considered "overtreatment" in inactive patients with moderate glenoid bone loss. Several studies have described an arthroscopic technique called arthroscopic subscapularis augmentation. We developed a technical variation of the arthroscopic subscapularis augmentation technique involving tenodesis of the upper third of the subscapularis tendon using a graft. This technique uses a transglenoid fixation-immobilization with 2 knotless TightRope devices instead of anchors.

Bankart repair with subscapularis augmentation: A case control study

To examine the effect on functional shoulder scores of Bankart repair with arthroscopic subscapularis tendon augmentation applied to cases of anterior shoulder instability with < 25% glenoid defect and ligament-labral failure. A total of 83 patients underwent Bankart repair with subscapularis tendon augmentation between 2015 and 2021. The range of movement of the patients was measured by 2 doctors using a goniometer. The Constant Murley score, American Shoulder and Elbow Surgeons score, Rowe score, and the University of California at Los Angeles scores were recorded preoperatively and postoperatively. Statistically significant increases were determined in the postoperative functional scores compared to the preoperative values as mean 41.4 ± 2.08 unit increase in the Constant Murley score, mean 41.4 ± 1.8 unit increase in the American Shoulder and Elbow Surgeons score, mean 13.8 ± 1.45 unit increase in the University of California at Los Angeles and mean 49.3 ± 7.45 unit increase in the Rowe score (P = .001; P < .01). Compared with the preoperative evaluation, there was found to be a postoperative statistically significant unit decrease of 10.2 ± 1.47 in the external rotation measurement (P = .001; P < .01). The number of dislocations was determined to have a negative correlation with the internal rotation measurements (r = -0.305; P = .005; P < .01), and a weak negative statistically significant relationship with external rotation measurements (r = -0.329; P = .002; P < .01). Unlike other techniques, as this repair technique includes both the tendon and the capsule as a single piece, it was seen to be a sufficient and reliable technique that is easy-to apply.

Arthroscopic Biceps Transfer to the Glenoid With Bankart Repair Grants Satisfactory 2-Year Results for Recurrent Anteroinferior Glenohumeral Instability in Subcritical Bone Loss

PURPOSE

To evaluate the short-term outcomes of the arthroscopic dynamic anterior stabilization (DAS), which is a transfer of the intra-articular portion of the long head biceps through the subscapularis split and fixation on the anterior glenoid, combined with a Bankart repair.

METHODS

A retrospective evaluation was performed of DAS and a minimum of 2-year follow-up. Inclusion criteria were the presence of anteroinferior instability, a positive apprehension test at 90° of abduction and external rotation, and subcritical glenoid bone loss (less than 20%). Exclusion criteria were severe (≥20%) glenoid bone loss, presence of biceps lesions or rupture (spontaneous or biceps tenotomy), pre-existing glenohumeral osteoarthritis, multidirectional or voluntary instability, previous arthroscopic stabilization procedure, and epilepsy. Outcomes included the Rowe score, range of motion (ROM), and recurrence.

RESULTS

Twenty-three patients were treated with DAS and arthroscopic Bankart repair during the study period. One person was lost to follow-up, leaving 22 patients available at last follow-up. Those 22 patients had an average age of 31.9 ± 12.3 years (range, 18-68) and were evaluated at an average follow-up of 3.2 ± 0.7 years (range, 1.2-4.2). The Rowe score increased from 36.1 ± 16.2 (range, 10-70) preoperatively to 89.8 ± 20.1 (range, 30-100) postoperatively (P < .001) with almost all patients (90.9%) improving their score beyond the minimal clinically important difference of 9.7 points. Postoperatively, ROM was maintained. Three patients (13.6%) analyzed at final follow-up demonstrated recurrence, one was successfully treated conservatively, but two revised with a Latarjet. No postoperative Popeye deformity, biceps cramping, or other complication were reported.

CONCLUSIONS

The DAS procedure may be an option for augmentation of a Bankart repair in patients with anterior shoulder instability and subcritical bone loss. ROM is maintained without evidence of postoperative Popeye deformity or biceps cramping.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Editorial Commentary: Augmented Bankart Could Be the Right Option for Subcritical Bone Loss

The suitable treatment for recurrent anterior shoulder instability with subcritical glenoid bone loss remains controversial. Although the Latarjet procedure is one of the most successful surgery for shoulder instability, it has been associated with potential complications in my patients with limited bone loss and poor soft-tissue conditions, which motivated me to further investigate Bankart augmentation techniques. A myriad of them have been devised and proposed for this specific group of patients; however, there are no sufficient clinical data reported in the literature to support one of them particularly or clarify in which situation they should be used. Further comparative and prospective studies are therefore needed to build an evidence-based decision tree to help us treating our patients and better match their expectations. That said, current literature and my experience have resulted in a shift in my treatment paradigm undertaken 3 years ago to augmented Bankart in case of subcritical glenoid bone loss.

Does glenoid remodeling occur with an erosion-type bone loss after arthroscopic Bankart repair?

Introduction

Fragment-type glenoid bone loss is known to remodel after arthroscopic Bankart repair. To our knowledge, no studies have been reported about the morphologic changes of the erosion-type bone loss.

Aim

To determine the morphologic changes of erosion-type glenoid bone loss after arthroscopic Bankart repair.

Methods

Twenty-eight patients (mean age: 31 years) with traumatic anterior glenohumeral instability with an erosion-type glenoid bone loss <25% underwent arthroscopic Bankart repair. The minimum follow-up was 2 years. Pre- and postoperative bilateral computed tomography scans were performed in all patients. The width and surface area of the glenoid were measured by a software program and compared pre- and postoperatively.

Results

The recurrence rate was 7.1% (2 of 28 shoulders). The size of the bone loss was 7.2% ± 5.3% (mean ± standard deviation). The preoperative glenoid width and area were 24.9 ± 2.2 mm and 7.0 ± 0.8 cm², respectively, and the postoperative ones (2 years after surgery) were 24.7 ± 2.2 mm and 6.8 ± 0.8 cm², respectively. There were no significant differences between the pre- and postoperative glenoid width and area.

Discussion and conclusion

Unlike the fragment-type bone loss, the erosion-type bone loss <25% did not show any morphologic changes of the glenoid at least 2 years after arthroscopic Bankart repair.

The novel arthroscopic subscapular sling procedure grants better stability than an arthroscopic Bankart repair in a cadaveric study

PURPOSE

This novel arthroscopic subscapular sling procedure stabilizes the shoulder using a semitendinosus graft to create a sling around the subscapular tendon, which provides both static and dynamic stability. The aim of the study was to evaluate the biomechanical stability of the subscapular sling procedure in human cadaveric shoulders. The hypothesis was that the sling offers an equal stabilizing effect and range of motion compared to an arthroscopic Bankart repair.

METHODS

Sixteen shoulders were investigated using an industrial robot-based testing platform and four different conditions: the physiologically intact shoulder, after creating a Bankart lesion, after arthroscopic Bankart repair, and finally after applying the subscapular sling procedure using a semitendinosus tendon graft. Joint translation and external rotation were evaluated for each condition.

RESULTS

The results show improved stability in the shoulders with the subscapular sling. The robot testing revealed a significant reduction in translation in anterior and anterior-inferior directions compared to the arthroscopic Bankart repair. None of the shoulders were dislocated by forced manual abduction and external rotation. No difficulties were encountered in performing the arthroscopic subscapular sling procedure. Thorough postoperative anatomical dissection showed no alterations to structures at risk.

CONCLUSION

The biomechanical results show increased stability with the use of the subscapular sling method.

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.

Arthroscopic Posterior Glenohumeral Capsular Augmentation With Gracilis Tendon Allograft

Recurrent shoulder instability complicated by capsular insufficiency due to underlying soft-tissue disorders or multiple prior failed surgical procedures poses a challenging surgical problem. Traditional capsulolabral soft-tissue reconstruction techniques are less effective in this setting, and bony procedures sacrifice normal anatomic relations. The described arthroscopic technique aims to prevent instability while maintaining range of motion through creation of a soft-tissue allograft "sling" augmenting the posterior glenohumeral capsule.

Labral Repair Augmentation by Labroplasty and Simultaneous Trans-Subscapular Transposition of the Long Head of the Biceps

Chronic traumatic anteroinferior instability is a common pathology of the shoulder joint. In case of glenoid bone defects, the Latarjet or bone block technique is the method of choice. The arthroscopic Bankart procedure and its modifications remain the preferred methods of treating patients without substantial bone damage of the glenoid and humeral head; however, there is a high recurrence of instability after the Bankart procedure, even for optimal indications. One of the main causes of recurrence is poor quality and weakness of the glenohumeral ligaments and labrum. We describe an alternative technique that provides triple mechanisms of stabilization like the Latarjet procedure. In our procedure, the long head of the biceps tendon is used for a sling effect, dynamic stabilization is achieved by trans-subscapular tenodesis with simultaneous plasty of the anterior segment of the labrum, and subsequent resuspension of the glenohumeral ligaments is performed using the same anchors. In patients without substantial bone loss, this procedure has numerous advantages over the arthroscopic Latarjet procedure. By creating triple mechanisms of stability like the Latarjet procedure (the bumper effect, reinforcement of ligaments, and sling effect), our procedure can significantly reinforce the Bankart procedure in cases of poor-quality glenohumeral ligaments.

Dynamic Anterior Stabilization Using the Long Head of the Biceps for Anteroinferior Glenohumeral Instability

Anteroinferior glenohumeral instability can be treated by variants of the Bankart repair, remplissage, and the Latarjet procedure, although all options remain associated with complications, including recurrence, stiffness, persistent pain, apprehension, and dislocation arthropathy. The authors therefore thought of a concept of dynamic anterior stabilization to treat anteroinferior glenohumeral instability by transferring the long head of the biceps within a subscapularis split to the anterior glenoid margin, thereby creating a "sling effect" by using a conservative technique. A standard Bankart repair is then to re-establish the labral damper effect. The main benefit of the dynamic anterior stabilization procedure is that it grants the "sling effect," but is easier and safer than arthroscopic Latarjet. It does not require screws nor traction of the coracoid process, and should therefore reduce the risks of neurologic damage. Furthermore, the procedure can be performed with only 3 small incisions, because it does not require coracoid transfer, which eliminates risks of nerve dissection, graft overhang, and cortical resorption, hence reducing the probability for dislocation arthroplasty. Lastly, the pectoralis minor remains intact, which would avoid scapular dyskinesis.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The effect of the arthroscopic augmentation of the subscapularis tendon on shoulder instability and range of motion: A biomechanical study

BACKGROUND

Anterior shoulder dislocation is common. The treatment of recurrence with glenoid bone defect is still considered controversial. A new arthroscopic subscapularis augmentation has recently been described that functions to decrease the anterior translation of the humeral head. The purpose of the presented study was to examine the biomechanical effect on glenohumeral joint motion and stability.

METHODS

Eight fresh frozen cadaver shoulders were studied by use of a force guided industrial robot fitted with a six-component force-moment sensor to which the humerus was attached. The testing protocol includes measurement of glenohumeral translation in the anterior, anterior-inferior and inferior directions at 0°, 30° and 60° of glenohumeral abduction, respectively, with a passive humerus load of 30N in the testing direction. The maximum possible external rotation was measured at each abduction angle applying a moment of 1Nm. Each specimen was measured in a physiologic state, as well as after Bankart lesion with an anterior bone defect of 15-20% of the glenoid, after arthroscopic subscapularis augmentation and after Bankart repair.

FINDINGS

The arthroscopic subscapularis augmentation decreased the anterior and anterior-inferior translation. The Bankart repair did not restore the mechanical stability compared to the physiologic shoulder group. External rotation was decreased after arthroscopic subscapularis augmentation compared to the physiologic state, however, the limitation of external rotation was decreased at 60° abduction.

INTERPRETATION

The arthroscopic subscapularis augmentation investigated herein was observed to restore shoulder stability in an experimental model.

Arthroscopic Bankart repair and subscapularis augmentation: an alternative technique treating anterior shoulder instability with bone loss

BACKGROUND

This study presents the preliminary results of a new arthroscopic technique consisting of the association of 2 procedures, capsulolabral repair and subscapularis augmentation tenodesis, in the treatment of traumatic anterior shoulder instability with both glenoid bone loss and a Hill-Sachs lesion.

METHODS

Eighty-nine patients engaged in sports were enrolled in this retrospective case-series study with 2 to 5 years' follow-up. All patients underwent a computed tomography scan to assess the percentage of glenoid bone loss by the Pico method. A prior stabilization procedure had failed in 20 patients, who were then segregated into a different group. Visual analog scale (VAS), Rowe, and American Shoulder and Elbow Surgeons (ASES) scores were used to assess the results.

RESULTS

Only 3 of 89 patients had a post-traumatic redislocation. The mean length of follow-up was 31.5 months (range, 25-60 months). The VAS, Rowe, and ASES scores showed significant improvements: The VAS score decreased from a mean of 3.1 to 0.5 (P = .0157), the Rowe score increased from 58.9 to 94.1 (P = .0215), and the ASES score increased from 68.5 to 95.5 (P = .0197). The mean deficit of external rotation was 6° with the arm at the side of the trunk, and the mean deficit was 3° with the arm in 90° of abduction.

CONCLUSIONS

The described procedure is a reproducible and effective technique used to restore joint stability in patients engaged in sports who have incurred anterior recurrent shoulder dislocation associated with glenoid bone loss (<25%) and a Hill-Sachs lesion.

Arthroscopic augmentation with subscapularis tendon in anterior shoulder instability with capsulolabral deficiency

The treatment of chronic shoulder instability with poor quality of the anterior capsulolabral tissue is still controversial. In these cases the Latarjet procedure is certainly more effective in preventing recurrence than an arthroscopic capsular repair. However, several studies have reported a variety of severe complications related to the Latarjet procedure because of the use of bone augmentation and hardware implantation; moreover, the arthroscopic version of the Latarjet procedure is technically difficult and potentially dangerous because of the proximity of neurovascular structures. The aim of this report is to describe an innovative arthroscopic technique consisting of an augmentation of the anterior capsulolabral tissue using the articular portion of the subscapularis tendon and knotless suture anchors paired with high-strength tape for its fixation to the anterior glenoid edge. In the absence of severe bone deficiency of the anterior glenoid edge, this procedure can minimize arthroscopic technique failures, restoring the anterior capsulolabral wall without any significant reduction of shoulder functionality.