Arthroscopic Knotless, Tensionable All-Suture Anchor Bankart Repair

Arthroscopic Management of the Contact Athlete with Anterior Instability

Anterior glenohumeral instability is one of the most common injuries suffered from sport. Despite padding and conditioning, the shoulder joint remains particularly vulnerable to injury, especially in the setting of contact. The overall rate of anterior instability is reported to be 0.12 injuries per 1000 athlete exposures, although this is increased up to 0.40 to 0.51 in the contact athlete. Successful treatment requires consideration of restoring stability while minimizing loss of glenohumeral motion. Common treatment strategies involve addressing the pathology that results from anterior shoulder dislocation including labral detachment as well as bony defects to the humeral head and glenoid.

Outcomes of primary arthroscopic shoulder stabilization in active patients over 40-results at a mean follow-up of 7 years

Background

The purpose of this study is to report clinical outcomes, return to activity, redislocation rate, and rate of conversion to arthroplasty for active patients over age 40 undergoing primary arthroscopic shoulder stabilization.

Methods

Patients over 40 years of age who underwent arthroscopic capsulolabral repair for shoulder instability between December 2005 and January 2018 with a minimum of 2-year postoperative follow-up were enrolled in this retrospective, monocentric study. Clinical outcome scores including the 12-Item Short-Form Survey, American Shoulder and Elbow Surgeons (ASES), Quick Disabilities of the Arm, Shoulder, and Hand, Single-Assessment Numeric Evaluation, and visual analog scale pain were collected. Additionally, it was determined which patients reached the minimal clinically important difference and the patient-acceptable symptom state for the ASES score. Bivariate analysis was utilized to determine if there was any association between baseline demographic and clinical factors with the outcome scores.

Results

Of a total of 814 patients assessed for eligibility, an aggregate of 40 patients were included and 33 patients (8 females) were available for follow-up. The average age was 49.4 ± 7.6 years. At an average follow-up of 7.0 ± 3.6 years, all the outcome scores significantly improved compared to baseline. These included ASES (69.9 ± 19 to 95.8 ± 7.6, P < .001); the Quick Disabilities of the Arm, Shoulder, and Hand score (29.7 ± 17.7 to 3.9 ± 5.4, P < .002); Single Assessment Numeric Evaluation score (53.5 ± 29.3 to 91.6 ± 14.3, P < .003); the 12-Item Short-Form Survey (45.6 ± 8.8 to 55.2 ± 5.7, P < .001); and the visual analog scale (2.1 ± 2.1 to 0.3 ± 1, P < .002). The minimal clinically important difference was reached by 72.7% of the patients and 81.8% reached the patient-acceptable symptom state threshold for the ASES score. Postoperative shoulder stability improved substantially and significantly. Median postoperative satisfaction was 10/10 (range 1-10). Ninety-five-point-six percent of the patients returned to sport, with 91.0% of the patients able to return to preinjury level. One patient (3%) underwent revision surgery for osteoarthritis, in the form of comprehensive arthroscopic management procedure. The presence of cartilage defects cartilage defects Outerbridge grade >2 (P = .020) and posterior labral lesions (P = .03) at index surgery were significantly associated with inferior outcomes in the ASES score.

Conclusion

Active patients aged 40 years and older undergoing arthroscopic shoulder stabilization experienced favorable functional outcomes at a mean follow-up of 7 years, with low rates of revision surgery or of progression to clinically relevant osteoarthritis. However, the presence of high-grade cartilage lesions and the presence of a posterior labral tear were associated with inferior clinical outcomes.

Outcomes of total shoulder arthroplasty in patients with prior anterior shoulder instability: minimum 5-year follow-up

BACKGROUND

Patients with a history of anterior shoulder instability (ASI) commonly progress to glenohumeral arthritis or even dislocation arthropathy and often require total shoulder arthroplasty (TSA). The purposes of this study were to (1) report patient-reported outcomes (PROs) after TSA in patients with a history of ASI, (2) compare TSA outcomes of patients whose ASI was managed operatively vs. nonoperatively, and (3) report PROs of TSA in patients who previously underwent arthroscopic vs. open ASI management.

METHODS

Patients were included if they had a history of ASI and had undergone TSA ≥5 years earlier, performed by a single surgeon, between October 2005 and January 2017. The exclusion criteria included prior rotator cuff repair, hemiarthroplasty, or glenohumeral joint infection before the index TSA procedure. Patients were separated into 2 groups: those whose ASI was previously operatively managed and those whose ASI was treated nonoperatively. This was a retrospective review of prospective collected data. Data collected was demographic, surgical and subjective. The PROs used were the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score. Failure was defined as revision TSA surgery, conversion to reverse TSA, or prosthetic joint infection. Kaplan-Meier survivorship analysis was performed.

RESULTS

This study included 36 patients (27 men and 9 women) with a mean age of 56.4 years (range, 18.8-72.2 years). Patients in the operative ASI group were younger than those in the nonoperative ASI group (50.6 years vs. 64.0 years, P < .001). Operative ASI patients underwent 10 open and 11 arthroscopic anterior stabilization surgical procedures prior to TSA (mean, 2 procedures; range, 1-4 procedures). TSA failure occurred in 6 of 21 patients with operative ASI (28.6%), whereas no failures occurred in the nonoperative ASI group (P = .03). Follow-up was obtained in 28 of 30 eligible patients (93%) at an average of 7.45 years (range, 5.0-13.6 years). In the collective cohort, the American Shoulder and Elbow Surgeons score, Single Assessment Numerical Evaluation score, QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) score, and 12-item Short Form physical component score significantly improved, with no differences in the postoperative PROs between the 2 groups. We found no significant differences when comparing PROs between prior open and prior arthroscopic ASI procedures or when comparing the number of prior ASI procedures. Kaplan-Meier analysis demonstrated a 79% 5-year survivorship rate in patients with prior ASI surgery and a 100% survivorship rate in nonoperatively managed ASI patients (P = .030).

CONCLUSION

At mid-term follow-up, patients with a history of ASI undergoing TSA can expect continued improvement in function compared with preoperative values. However, TSA survivorship is decreased in patients with a history of ASI surgery compared with those without prior surgery.

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.

Management of Shoulder Instability in Patients with Underlying Hyperlaxity

PURPOSE OF REVIEW

Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD).

RECENT FINDINGS

Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.

Portal Closure After Segmental Posterior Labral Repair for Posterior Shoulder Instability

Posterior instability, although an uncommon shoulder pathology, is reported most frequently in the athletic population. Arthroscopic repair has emerged as the main surgical treatment modality for posterior instability. However, when compared with arthroscopic repair for anterior instability, the results of this procedure remain suboptimal. The creation of iatrogenic defects in the capsule, due to cannula placement, is a possible culprit. Because these defects typically do not heal satisfactorily, they become stress risers within the capsule itself, which may lead to recurrent instability or an otherwise compromised repair construct. Therefore, we find that routine intraoperative repair of these defects after repair can reduce the risk of injury and possibly improve long-term outcomes. In this article, we illustrate the repair of a posterior segmental tear using all-suture knotless implants with closure of the posterior and posterior-inferior portals after stabilization.

Knotless All-Suture, Soft Anchor Bankart Repair Results in Excellent Patient-Reported Outcomes, High Patient Satisfaction, and Acceptable Recurrent Instability Rates at Minimum 2-Year Follow-Up

PURPOSE

The purpose of this study was to evaluate minimum 2-year outcomes after arthroscopic knotless all-suture soft anchor Bankart repair in patients with anterior shoulder instability.

METHODS

This was a retrospective case series of patients who underwent Bankart repair using soft, all-suture, knotless anchors (FiberTak anchors) from 10/2017 to 06/2019. Exclusion criteria were concomitant bony Bankart lesion, shoulder pathology other than that involving the superior labrum or long head biceps tendon, or previous shoulder surgery. Scores collected preoperatively and postoperatively included SF-12 PCS, ASES, SANE, QuickDASH, and patient satisfaction with various sports participation questions. Surgical failure was defined as revision instability surgery or redislocation requiring reduction.

RESULTS

A total of 31 active patients, 8 females and 23 males, with a mean age of 29 (range: 16-55) years were included. At a mean of 2.6 years (range: 2.0-4.0), patient-reported outcomes significantly improved over preoperative levels. ASES score improved from 69.9 to 93.3 (P < .001), SANE improved from 56.3 to 93.8 (P < .001), QuickDASH improved from 32.1 to 6.3 (P < .001) and SF-12 PCS improved from 45.6 to 55.7 (P < .001). Median patient postoperative satisfaction was 10/10 (range: 4-10). Patients reported a significant improvement sports participation (P < .001), pain with competition (P = .001), ability to compete in sports (P < .001), painless use of arm for overhead activities (P = .001), and shoulder function during recreational sporting activity (P < .001). Postoperative shoulder redislocations were reported in 4 cases (12.9%)-all after major trauma-with 2 patients progressing to Latarjet (6.45%) at 2 and 3 years postoperatively. There were no cases of postoperative instability without major trauma.

CONCLUSIONS

Knotless all-suture, soft anchor Bankart repair resulted in excellent patient-reported outcomes, high patient satisfaction, and acceptable recurrent instability rates, in this series of active patients. Redislocation after arthroscopic Bankart repair with a soft, all-suture anchor only occurred after return to competitive sports with new high-level trauma.

STUDY DESIGN

Level IV, retrospective cohort study.

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.

Arthroscopic repair of rotator cuff injury with bioabsorbable suture anchor vs. all-suture anchor: a non-inferiority study

BACKGROUND

Compare all-suture anchors to traditional anchors through clinical and radiological evaluation at pre-established end-points.

MATERIALS AND METHODS

We performed a two-arms non-inferiority study on all-suture anchor (2.3 iconix™, Stryker) device with respect to traditional anchor (5.5 healix Advance™ BR, Depuy/Mitek) device under unpaired samples with size equal to 30 patients per group, all suffering from supraspinatus tendon rupture. We administrated DASH (Disabilities of the Arm, Shoulder and Hand); constant; and SST (Simple Shoulder Test) questionnaires in pre-operative, 3 ± 1 months post-intervention and 8 ± 1 months post-intervention. Questionnaires scores were the primary outcome. We also evaluated RMI at 3 and at 8 months after surgery to assess the presence of oedema or any loosening of the implant.

RESULTS

All-suture anchor approach has been proven to have non-inferior performances with respect to traditional anchor approach, according to questionnaires scores at the 3-month endpoint. We observed 26 patients with oedema by MRI (18 in control group, 6 in experimental group). In the 8-month endpoint we found persistent edema in 12 patients (all treated with healix), 2 had mobilitazions (healix), 10 had partial retears (8 healix, 2 iconix) and 1 implant failure (healix).

CONCLUSIONS

All suture devices have clinical and functional results comparable to traditional devices, while they tend to give fewer complications in terms of bone edema, loosening and retear rate. The effectiveness of all-suture devices should be further investigated in rotator cuff suture arthroscopic revision surgery, given the advantages they offer.

Clinical Outcomes After Arthroscopic Pancapsular Shift for the Treatment of Multidirectional Glenohumeral Instability at a Mean Follow-up of 9 Years

BACKGROUND

Arthroscopic treatment of multidirectional instability (MDI) of the shoulder is being increasingly performed, but there is a paucity of studies with minimum 5-year follow-up.

PURPOSE

To report on survivorship and patient-reported outcomes (PROs) after arthroscopic pancapsulorraphy (APC) for MDI with a minimum 5-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Institutional review board approval was obtained before initiation of this retrospective review of prospectively collected data. Patients were included if they had a minimum of follow-up 5 years after APC for MDI. PROs included the 12-Item Short Form Health Survey Physical Component Summary; American Shoulder and Elbow Surgeons; Single Assessment Numeric Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; and patient satisfaction. Preoperative, short-term (1-2 years), and final follow-up PROs were compared. Recurrent instability, dislocation, and reoperation were collected, and survivorship analysis was performed.

RESULTS

A total of 49 shoulders in 44 patients (15 male, 29 female) treated between October 2005 and November 2015 were included in the study. MDI onset was atraumatic in 27 shoulders and traumatic in 22. Rotator interval closure was performed in 17 patients. Overall, 14 of 49 (29%) patients reported feelings of instability in the shoulder, of whom 5 (10.2%) underwent revision surgery at a mean of 1.5 years. Kaplan-Meier analysis demonstrated a survivorship rate of 88% at 5 years and 82% at 8 years, with failure defined as requiring revision surgery or postoperative feelings of instability with ASES score <65. Final outcome analysis was performed on 41 shoulders with a mean follow-up of 9.0 years (range, 5.1-14.6 years). All PROs demonstrated significant improvement from preoperative baseline (P < .05) and remained significantly improved at both short-term and long-term final follow-up. There was no difference in PROs based on \\ atraumatic versus traumatic onset, or patients treated with a rotator interval closure. There was a significant difference in PROs between patients who had continued instability.

CONCLUSION

APC for the treatment of MDI provided reasonable, durable long-term PROs that persisted from short-term follow-up. Although 29% of patients experienced feelings of instability at final follow-up, most of these patients still had high postoperative satisfaction and acceptable PROs.

Arthroscopic Reduction and Internal Fixation of an Osseous Bankart Lesion

Operative treatment of anterior glenohumeral instability is challenging, particularly with the presence of an anterior glenoid rim fracture, also called an "osseous Bankart lesion." Successful reduction and fixation of the lesion has been shown to greatly reduce the risk of recurrent dislocations while achieving osseous union and normalization of glenoid anatomy¹.

Description

The current surgical video article outlines a technique for an osseous Bankart repair in a patient with a displaced fracture as well as substantial pain and instability. First, the amount of bone loss is measured on 3-dimensionally reconstructed computed tomography (CT) imaging, with the humeral head digitally subtracted². The procedure is then performed arthroscopically with the patient in the lateral decubitus position. A diagnostic evaluation, beginning with posterior and anterior portal placement in the rotator interval, is completed to assess any rotator cuff injury and the extent of labral tearing and osseous displacement. Next, the bone fragment is elevated into its anatomical position. This fragment is then reduced with use of a double-row suture technique, followed by concomitant capsulolabral repair.

Alternatives

Nonoperative treatment with a sling can be utilized as long as post-reduction CT scans reveal anteroposterior centering of the humeral head on the glenoid³. Rehabilitation can include active-assisted and passive glenohumeral mobilization, as well as daily pendulum exercises and physiotherapy.

Rationale

Osseous Bankart repair has been shown to effectively improve patient-reported outcomes and normalize glenoid morphology^1,3,4. Failure to recognize and appropriately treat an osseous Bankart fracture may lead to osseous erosion caused by repetitive episodes of subluxations or dislocations, along with substantial pain and weakness⁵. Indications for arthroscopic Bankart repair include young, active patients with a reducible fracture fragment, an anterior glenoid deficit of >10%, and a history of failed nonoperative treatment^3-8.

Expected Outcomes

Clinical outcomes following the osseous Bankart repair procedure have been shown to be highly successful, with high rates of return to sport, minimal reduction in range of motion, and restoration of shoulder function and stability⁴. Additionally, long-term follow-up has shown successful osseous union and normalization of glenoid anatomy¹.

Important Tips

Apply tension to sutures with a suture retriever before the PushLock anchors (Arthrex) are placed during fracture reduction.Utilize a trans-subscapularis portal for anchor placement medial to the fracture on the glenoid neck.Perform adjustable tensioning during labral repair with knotless all-suture anchors.Utilize a lateral distraction device with the patient in the lateral decubitus position to completely visualize the anteroinferior glenoid.Chronic onset and late intervention may cause difficulties in the reduction of the bone fragment.Suture management may be difficult, particularly for surgeons at an early stage of the learning curve.A defect that is wide (from medial to lateral) may be difficult to maneuver around and reduce.

Acronyms and Abbreviations

GH = glenohumeralGHL = glenohumeral ligamentPts = patientsPMH = previous medical historyFE = forward elevationER = external rotationIR = internal rotationABD = abductionEXT = external rotationXR = radiographic imagingMRI = magnetic resonance imagingCT = computed tomographyROM = range of motionFU = follow-upRTS = return to sportsRTPP = return to previous level of play.

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up

BACKGROUND

Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair.

PURPOSE

To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed.

RESULTS

A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively (P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 (P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) (P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years (P = .311).

CONCLUSION

Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

Arthroscopic Remplissage Using Knotless, All-Suture Anchors

Glenohumeral bone loss is a significant risk factor for recurrent instability after shoulder dislocation. The Hill-Sachs lesion is an osseous defect of the posterior humeral head that is commonly recognized after anterior shoulder dislocation. Several procedures exist to address humeral-sided bone loss, including soft tissue filling procedures, osteoarticular allografts, bone plugs, rotation osteotomies, and humeral head replacements. However, among the most common of these procedures is the arthroscopic remplissage. This technique involves capsulotenodesis of the posterior shoulder capsule and infraspinatus tendon into a Hill-Sachs lesion. Previously described techniques use knotted suture anchors. In this report, we describe a modified technique for remplissage using knotless, all-suture anchors to perform capsulotenodesis of a Hill-Sachs lesion. Benefits of this technique include a single skin incision, improved bone preservation, and easier facilitation of revision surgery if required.

Intramedullary Unicortical Button and All-Suture Anchors Provide Similar Maximum Strength for Onlay Distal Biceps Tendon Repair

PURPOSE

To evaluate the biomechanical profile of onlay distal biceps repair with an intramedullary unicortical button versus all-suture anchors under cyclic loading and maximal load to failure.

METHODS

Twenty paired fresh-frozen human cadaveric elbows were randomized to onlay distal biceps repair with either a single intramedullary button or with two 1.35-mm all-suture anchors. A 1.3-mm high tensile strength tape was used in a Krackow stitch to suture the tendons in both groups. Specimens and repair constructs were loaded for 3,000 cycles and then loaded to failure. Maximum load to failure, mode of failure, and construct elongation were recorded.

RESULTS

Mean (± standard deviation) maximum load to failure for the unicortical intramedullary button and all-suture anchor repairs were 503.23 ± 141.77 N and 537.33 ± 262.13 N (P = .696), respectively. Mean maximum displacement after 3,000 cycles (± standard deviation) was 4.17 ± 2.05 mm in the button group and 2.06 ± 1.05 mm in the suture anchor group (P = .014). Mode of failure in the button group was suture tape rupture in 7 specimens, failure at the tendon-suture interface in 2 specimens, and button pullout in 1 specimen. Anchor pullout was the mode of failure in all suture anchor specimens. There were no tendon ruptures or radial tuberosity fractures in either group.

CONCLUSIONS

This study demonstrates that onlay distal biceps repair with 2 all-suture anchors has similar maximum strength to repair with an intramedullary button and that both are viable options for fixation.

CLINICAL RELEVANCE

All-suture anchors and unicortical intramedullary button have similar maximum strength at time zero. Both constructs provide suitable fixation for onlay distal biceps repair.

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.

Single-Portal, Single-Anchor Repair of a Superior Third Subscapularis Tear Using a Self-Punching Knotless Soft Suture Anchor

Numerous techniques exist for arthroscopic subscapularis repair with varying degrees of complexity based on tear morphology, all of which have established satisfactory outcomes in function and patient satisfaction. Arthroscopic subscapularis repair can require several working portals and suture anchors, increasing both technical complexity and operative time. This Technical Note describes an arthroscopic repair of a superior one-third subscapularis tear using a self-punching knotless soft suture anchor through a single anterior working portal. Thus, we offer a unique approach to arthroscopic repair of superior one-third subscapularis tears that is time-saving, reproducible, and highly efficient while minimizing iatrogenic damage and postoperative complications.

Comparison of efficacy between montgomery and Jobe technique and arthroscopic bankart repair in treating traumatic recurrent anterior shoulder dislocation

OBJECTIVE

To compare the clinical efficacy of Montgomery and Jobe technique versus arthroscopic Bankart repair in treating traumatic recurrent anterior shoulder dislocation (ASD).

METHODS

A total of 113 patients with traumatic recurrent ASD admitted to our hospital from June 2016 to January 2019 were selected as study subjects, and were divided into Group A and B in accordance with surgical options. The clinical data of the subjects were collected retrospectively. Group A was treated by the Montgomery and Jobe technique, while Group B was treated with arthroscopic Bankart repair. The arthroscopic manifestations were analyzed before and after arthroscopic Bankart repair. Scores of visual analogue scale (VAS) for shoulder joint and American Shoulder and Elbow Surgeons (ASES), Constant-Murley Score (CMS), Rowe Score, and complications were compared between the two groups before and after surgery.

RESULTS

Compared with Group A, Group B had a lower score of VAS for the shoulder joint, and higher scores of the range of motion (ROM), functional activities, myodynamia, pain, CMS, vital functions, ASES, and shoulder joint function, and a higher Rowe score after surgery (P < 0.05). The incidence rate (1.75%) of complications in Group B was lower than that (14.29%) in Group A (P < 0.05).

CONCLUSION

Arthroscopic Bankart repair is superior to the Montgomery and Jobe technique in treating traumatic recurrent ASD. Arthroscopic Bankart repair, exhibiting a high safety profile, is conducive to improving shoulder joint function and pain.

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

PURPOSE

To compare rates of recurrent instability, revision surgery and functional outcomes following arthroscopic anterior capsulolabral repair for recurrent anterior instability using knot-tying versus knotless suture anchor techniques.

METHODS

 Patients who had undergone arthroscopic anterior labrum and capsular repair for recurrent anterior glenohumeral instability using knotless anchors were identified. Those with minimum 2-year follow-up were matched (1:2) to knot-tying anchor repair patients. Rates of failure and recurrent instability were compared, as well as Visual Analog Scale (VAS), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), University of California Los Angeles (UCLA) and Rowe scores.

RESULTS

One hundred and two patients (89 males, 13 females) with a mean age of 24.3 ± 9.6 were included. Repair was performed with knotless anchors in 34 and knot-tying anchors in 68 shoulders. At mean follow-up of 4.8 ± 2.5 years, re-dislocation rates between groups were not significantly different (knotless anchor: 9% versus knot-tying group: 15%, n.s.), but the knot-tying group showed a higher re-subluxation rate (p = 0.039). 12 (18%) revisions were performed in the knot-tying group at a mean 2.9 years after surgery and 1 (3%) revision in the knotless anchors group at 1.4 years (n.s.). There was no difference in mean VAS with use (1.3 ± 1.9 versus 0.8 ± 1.5, n.s.), SANE scores (91.8 ± 12.7 versus 92.0 ± 11.0, n.s.), QuickDASH scores (4.1 ± 5.5 versus 3.0 ± 6.5, n.s.), UCLA Shoulder Score (32.5 ± 3.6 versus 33.2 ± 3.1, n.s.), or Rowe scores (90.5 ± 18.5 versus 92.2 ± 16.6, n.s.) between knotless and knot-tying groups, respectively. VAS at rest was higher in the knotless group (0.7 ± 1.5 vs 0.1 ± 0.4, p = 0.021).

CONCLUSIONS

Knotless anchors demonstrated similar rates of re-dislocation and revision surgery, and lower rates of recurrent subluxation, compared to knot-tying anchors. Patients achieved good-to-excellent functional outcomes. This supports the efficacy of knotless anchors as an alternative to knot-tying anchors for arthroscopic anterior labral repair of recurrent anterior shoulder dislocation.

LEVEL OF EVIDENCE

III.

The Effect of Torque Differences for All-Suture Anchor Fixation Strength: A Biomechanical Analysis

Purpose

To investigate the biomechanical influence of differential loading of suture strands (torque) on the fixation strength of knotted and knotless all-suture anchors.

Methods

The biomechanical strength of 48 all-suture anchors was evaluated for 4 conditions in polyurethane foam blocks: (1) 12 knotted all-suture anchors loaded proportionately, (2) 12 knotted all-suture anchors with 1 suture strand bearing 50% of total force (partial torque), (3) 12 knotted all-suture anchors with 1 strand fixated and the other loaded (full torque), and (4) 12 knotless all-suture anchors with the loop kept open via a fixed rod. Force for 1 mm and 2 mm of displacement and ultimate failure load were assessed.

Results

For 1 mm of displacement, groups 2, 3, and 4 showed significantly lower forces than group 1 (all P < .001), with no statistically significant difference between groups 2 and 3 (P = .516); for 2 mm of displacement, all groups showed significantly lower forces than group 1 (P < .001), which positively correlated with applied torque. No differences in the mean ultimate loads observed between testing groups 1, 2, and 4 were noted, with 93.3 ± 3.8 N, 91.4 ± 4.7 N, and 92.6 ± 5.6 N, respectively; however, group 3 exhibited a significantly lower mean ultimate load (62.3 ± 1.7 N) than all other groups (P < .001).

Conclusions

The ultimate failure load of knotted and knotless all-suture anchor fixation was partially affected by loading differentials between strands in this validated foam block model. Differential loading of knotted all-suture anchor fixation presented greater initial displacement when compared with symmetrically loaded knotted all-suture anchors. Despite an initial increase in displacement, knotless all-suture anchors showed similar ultimate failure loads to knotted all-suture anchors with strands loaded equally.

Clinical Relevance

The role of suture strand loading imbalance on anchor fixation is variable and should be considered during placement and fixation of the repair constructs in a clinical setting.

Arthroscopic Bankart revision using all suture anchor in recurrent anterior shoulder dislocation: A case report

•

All suture anchor has the same biomechanical strength as conventional metallic anchor.

•

Recurrent shoulder dislocation after arthroscopic Bankart repair is still a problem.

•

The all suture anchor technique offers benefit of bone preservation and strong fixation.

Introduction

Arthroscopic Bankart revision after recurrent shoulder dislocation is still a matter of discussion. Several factors are contributing to this injury. Recently the development of all suture anchors has grown in popularity in arthroscopic stabilization. It was proven to preserve bone stock, smaller in size thus more anchors can be made.

Presentation of case

We presented a case of 27-year-old woman with recurrent anterior dislocation after seven years of arthroscopic Bankart repair. Seven years before, we performed Bankart repair using three 2.8 mm fiber-wire anchor (FASTak® (Arthrex, Karsfield Germany)). For the revision surgery we performed arthroscopic revision using four all suture anchor technique (Y-Knot® Flex All-Suture Anchor, 1.3 mm – One strand of #2 Hi-Fi® (Conmed, New York)).

Discussion

From preoperative and intraoperative assessment, we found no anchor failure and no massive bony lesion. To preserve the bone stock we insert four all suture anchors between the old anchor. One year post-operative follow up showed that patient could gain normal range of movement. No early or late complications were observed.

Conclusion

Compared to the conventional metallic anchor, all suture anchor has the same biomechanical strength. Moreover due to its relatively small size, it can reserve bone stock and more anchors can be made thus adding more stability to the shoulder.

All-suture anchors versus metal suture anchors in the arthroscopic treatment of traumatic anterior shoulder instability: A comparison of mid-term outcomes

OBJECTIVES

This study aims to compare metal suture anchors and all-suture anchors clinically and radiologically in arthroscopic Bankart repair.

PATIENTS AND METHODS

In this retrospective study, 67 patients (61 males, 6 females; mean age 26.0±5.8; range, 18 to 43 years) who underwent arthroscopic Bankart repair between April 2009 and October 2016 were divided into two groups depending on the type of the suture anchor used in different periods. Group A comprised 32 patients with arthroscopic Bankart repair performed with metal suture anchors, and Group B comprised 35 patients with arthroscopic Bankart repair performed with all-suture anchors. The patients were clinically evaluated using Rowe scores, Constant scores, redislocation rates, and positive apprehension test rates. Radiographic evaluation was performed using the Samilson-Prieto classification to observe the development of glenohumeral osteoarthritis.

RESULTS

The mean follow-up period was 41.1±10.4 (range, 30 to 60) months in Group A, and 39.6±9.4 (range, 28 to 60) months in Group B, with no significant difference between the two groups (p=0.559). No significant difference was observed between Group A and Group B in terms of mean Rowe score (89.2±13.8 [range, 40 to 100] vs. 88.7±16.9 [range, 25 to 100]; p=0.895) or Constant score (87.2±8.9 [range, 48 to 96] vs. 86.9±9.0 [range, 46 to 96]; p=0.878), which were the clinical outcomes at the final follow-up examination. Postoperative redislocation rates (3.1% vs. 2.9%, p=1.0) and positive apprehension test rates (6.3% vs. 8.6%, p=1.0) were found to be similar in both groups. According to the Samilson-Prieto classification, there was no evidence of glenohumeral osteoarthritis in any of the patients in either group.

CONCLUSION

Satisfactory outcomes were obtained with the use of all-suture anchors in arthroscopic Bankart repair for traumatic anterior shoulder instability. All-suture anchors and metal suture anchors, have similar outcomes in the mid-term and all-suture anchors are a reliable and effective option for arthroscopic Bankart repair.

The Bankart repair: past, present, and future

Arthur Sidney Blundell Bankart was a London-based orthopedic surgeon who discovered the essential lesion in recurrent anterior shoulder instability in 1923. He pioneered a technique, the Bankart repair, to re-establish stability to the glenohumeral joint, without sacrificing native joint motion. In this article, the original Bankart repair is compared to the modern arthroscopic Bankart repair, accompanied by a surgical video of Blundell Bankart performing the Bankart repair in 1951, shortly before his death. Bankart's original description included an open repair with a coracoid osteotomy and subscapularis tenotomy and repair. The history of the technique, its utility in present day, and the future of the Bankart repair are discussed.