Arthroscopic Bony Bankart Repair Using Suture Suspension to Increase Bone Contact Area

Arthroscopic Humeral Avulsion of the Glenohumeral Ligament (HAGL) Repair Utilized Accessory Posterior Portal in the Beach-Chair Position

Shoulder instability, often associated with both soft tissue and bone lesions, can result in shoulder pain and dysfunction. To address this, the combined procedure of a Bankart repair in conjunction with humeral avulsion of the glenohumeral ligament (HAGL) repair aims to minimize failure rates in a single procedure. While HAGL repair is imperative for preventing recurrent instability, there remains a lack of consensus on the optimal surgical technique. This Technical Note aims to elucidate a surgical approach for addressing and repairing HAGL lesions using arthroscopy, specifically employing a combined posterior viewing portal and posteroinferior working portal in the beach-chair position.

The Role of Arthroscopy in Contemporary Glenoid Fossa Fracture Fixation

Glenoid fossa fractures are rare injuries accounting for 10 to 29% of all intra-articular scapula fractures. They are usually the result of high-energy trauma, and concomitant injuries are not uncommon. Patients with glenoid fractures are admitted with shoulder pain and restricted range of motion. Although shoulder plain radiographs could establish the diagnosis, a computed tomography scan is necessary to adequately define the fracture pattern and characteristics. The most commonly used classification system is that of Ideberg (modified by Goss), which includes five glenoid fossa fracture types according to the location, extension, and complexity of the lesion. Articular surface displacement and step-off are the most important factors that should be taken under consideration when deciding for conservative or surgical management. Operative treatment includes open reduction and internal fixation through a posterior or anterior approach depending on fracture morphology and displacement. However, open surgical techniques are related to extensive soft-tissue disruption, risk of neurovascular injury, and inadequate exposure of the entire glenoid cavity. Introduction of arthroscopy could facilitate better visualization of the glenoid articular surface and improved fracture reduction. However, it is a technically demanding procedure with many challenges and pitfalls. The aim of this review is to summarize the current evidence regarding the treatment of glenoid fossa fractures and present the beneficial effect of arthroscopy in improving the quality of fracture fixation and overall functional outcomes.

Arthroscopic suture bridge fixation for acute bony Bankart with anterior glenohumeral instability: a case report and narrative review

Background and Objective

Anterior shoulder dislocations can result in acute glenoid rim fractures that compromise the bony stability of the glenohumeral joint. Adequate fixation of these fractures is required to restore stability, decrease shoulder pain, and facilitate return to activity. The double-row suture bridge is a relatively novel fixation technique, first described in 2009, that accomplishes internal fixation with sufficient stability using an all-arthroscopic technique to restore the glenoid footprint. A 40-year-old female with recurrent anterior shoulder instability in the setting of seizure disorder was found to have a bony Bankart lesion of 25% to 30% with a concomitant superior labral tear. The patient was treated with a double-row bony Bankart bridge and labral repair. At six months follow-up, she has progressed to a full recovery with no recurrence.

Methods

A search was conducted in May 2023 in PubMed, EMBASE, and CINAHL with the search terms bony Bankart, bone Bankart, osseous Bankart, acute, bridge, suture bridge, double row.

Key Content and Findings

Double-row suture bridge repairs result in improvement in shoulder function as determined by ASES (93.5), QuickDASH (4.5), SANE (95.9), and SF-12 (55.6). The overall recurrence rate of anterior instability after a bony Bankart bridge repair is 8%. When examining the return to prior level of function, 81.4% of patients were able to do so with only 7.9% of patients reporting significant modifications to their activity level. In mid-term results, double row suture bridge demonstrates similar outcomes to other all-arthroscopic fixation methods of bony Bankart injuries. Importantly, bony Bankart bridge remains a viable option for critical glenoid lesions over the 20% cutoff used in other all arthroscopic techniques. Biomechanically, the double-row suture bridge offers distinct benefits over its single-row counterpart including increased compression, reduced displacement, and reduced step-off.

Conclusions

Although there is limited data, the studies discussed and the demonstrative case show the potential benefit of all-arthroscopic double-row suture bridge fixation including increased compression, decreased displacement, and a lower complication rate in patients with large bony Bankart lesions traditionally requiring bony augmentation. However, more robust studies are necessary to determine the long-term success of the double-row suture bridge.

Single Working Portal Technique with 70-Degree Arthroscope for Arthroscopic Bankart Repair

The Bankart lesion is a common injury to the labrum in the shoulder joint, usually resulting from anterior shoulder dislocation. Arthroscopic Bankart repair is a surgical technique used to treat recurrent dislocations by reattaching the labrum to the glenoid rim using suture anchors. Typically, 3 portals are created: 1 for visualization and 2 for instrumentation. However, this Technical Note proposes a single working portal approach using a 70° arthroscope from the posterior portal. This technique enhances visualization and prevents portal jamming, particularly in cases with a small rotator interval.

Clinical Outcomes, Union Rates, and Complications of Screw Versus Button Fixation in the Bristow-Latarjet Procedure for Anterior Shoulder Instability: A Systematic Review and Meta-Analysis

Background

The Latarjet procedure is a common procedure for treating critical glenoid bone loss in anterior shoulder instability. Implants such as the screw and cortical button are widely used. The aim of this study was to compare studies on screw versus button fixation techniques in the Bristow-Latarjet procedure for anterior shoulder instability in terms of clinical outcomes, union rates, and complications.

Methods

The PubMed, Scopus, and Embase databases were searched to find comparative studies that reported outcomes of using screw versus button fixation in the Bristow-Latarjet procedure following the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Studies that directly compared the screw and button fixation techniques and provided postoperative patient-reported outcomes, union rates, or complications were included. The Methodology Index for Non-Randomized Research (MINORS) criteria were used to assess the quality of the included studies. Odds ratios (ORs) were calculated for dichotomous outcomes whereas mean differences were calculated for continuous outcomes.

Results

Five articles included a total of 877 shoulders. All five studies had level 3 evidence. There was no statistically significant difference between the two techniques using the Walch-Duplay score, visual analog scale for pain, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, range of motion, and graft union rates. However, the button fixation technique had statistically significantly higher recurrence rates than the screw fixation technique (OR, 0.24; 95% confidence interval, 0.10-0.58; p = 0.001).

Conclusions

The screw fixation technique had statistically significantly lower recurrence rates than the button fixation technique. However, there was no significant difference between screw and button fixation techniques regarding postoperative patient-reported outcomes, range of motion, graft union rates, nerve injury rates, infection rates, and reoperation rates.

Arthroscopic Repair of Acute Bony Bankart Lesion Following a Shoulder Dislocation Using Traction Sutures and Anchors: A Case Description

Management of shoulder dislocation can be challenging especially when glenoid bone fracture is involved. Bony Bankart lesion can be managed either through an open surgery or, of late, using arthroscopic technique. Arthroscopic bony Bankart repair is technically difficult, requiring specialized instruments to penetrate the bone fragment within the detached labrum. This case report describes an alternative way of doing an arthroscopic reattachment of an acute bony Bankart lesion using traction sutures, an accessory anteromedial portal and utilization of knotless anchors. A 44-year-old male technician was climbing a ladder when he slipped and fell directly on his left shoulder. Imaging revealed bony Bankart fracture with presence of ipsilateral greater tuberosity (GT) fracture and a Hill-Sachs lesion. In a right lateral position, arthroscopic reduction of the bony fragment was performed utilizing a Fibrewire® (Arthrex, Inc., Naples, FL, USA) suture as traction apparatus while securing the upper and lower tissue enveloping the bony Bankart fragment. An accessory portal was made lower down anteriorly to de-rotate the fragment, holding it in place while securing two Pushlock® (Arthrex, Inc.) anchors to the native glenoid. We then performed GT fixation using two cannulated screws. Check radiographs revealed acceptable reduction of the Bankart fragment. With careful case selection, arthroscopic repair of acute bony Bankart lesions is possible using special arthroscopic reduction maneuver and fixation technique with subsequent good outcome.

Arthroscopic double-row bridge fixation provided satisfactory shoulder functional restoration with high union rate for acute anterior glenoid fracture

PURPOSE

To introduce a novel surgical technique for arthroscopic reduction and double-row bridge fixation using trans-subscapularis tendon portal for anterior glenoid fracture and to evaluate the clinical and radiological outcomes.

METHODS

A total of 22 patients who underwent arthroscopic reduction and double-row bridge fixation for an acute anterior glenoid fracture were retrospectively evaluated. Arthroscopic surgery was performed using four portals including a trans-subscapularis tendon portal. All patients underwent 3D-CT preoperatively and one day and one year postoperatively to evaluate the fracture fragment size, reduction status, and presence of fracture union. To evaluate the degree of fragment displacement, articular step-off and medial fracture gap were measured using 3D-CT. Clinical outcomes were assessed based on the ASES and Constant scores. Postoperative glenohumeral joint arthritis was evaluated using plain radiographs with the Samilson and Prieto classification.

RESULTS

The average preoperative fracture fragment size was 25.9 ± 5.6%. Articular step-off (preoperative: 6.0 ± 3.3 mm, postoperative one day: 1.1 ± 1.6 mm, P < 0.001) and medial fracture gap (preoperative: 5.2 ± 2.6 mm, postoperative one day: 1.9 ± 2.3 mm, P < 0.001) were improved after surgery. On the postoperative one year 3D-CT, 20 patients achieved complete fracture union, and two patients showed partial union. Postoperative glenohumeral joint arthritis was observed in four patients. At the last visit, the ASES score was 91.8 ± 7.0 and the Constant score was 91.6 ± 7.0.

CONCLUSION

Arthroscopic reduction and double-row bridge fixation using a trans-subscapularis tendon portal for acute anterior glenoid fracture achieved satisfactory clinical outcomes and anatomical reduction as demonstrated by a low degree of articular step-off and medial fracture gap.

LEVEL OF EVIDENCE

Level IV.