Arthroscopic and open Bankart repairs provide similar outcomes

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Open Stabilization Procedures of the Shoulder in the Athlete: Indications, Techniques, and Outcomes

Shoulder instability is a relatively common injury especially in the young athletic population and its surgical management continues to remain a controversial topic in sports medicine orthopedics. Anterior instability is the most common type encountered and is estimated to have an incidence rate of 0.08 per 1000 person-years in the general population; however, this figure is likely higher in the young athletic population. While in recent practice, arthroscopic surgery has become the new gold standard for management, reported failure rates as high as 26% and high recurrence rates in specific subpopulations such as young men in high collision sports have led to the consideration of alternative open procedures such as open Bankart repair, Latarjet, capsular shift, and glenoid bone grafting. These procedures may be preferred in specific patient subgroups such as young athletes involved in contact sports and those with Hill-Sachs defects and multidirectional instability, with postoperative recurrence rates of instability as low as 10%. The purpose of this review is to provide an overview of different open surgical techniques in the management of shoulder instability and summarize patient outcomes including recurrence rates for shoulder instability, return to sport, range of motion (ROM), muscle strength, and complications either individually by procedure or in comparison with other techniques, with special focus on their impact in the athletic population.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Latarjet procedure versus open capsuloplasty in traumatic anterior shoulder dislocation: long-term clinical and functional results

PURPOSE

To compare the results of two different open surgical techniques (open capsuloplasty and Bristow-Latarjet procedure) at a mid- to long-term follow-up (6 years) in patients with recurrent traumatic anterior shoulder dislocations.

METHODS

Seventy-three patients (73 shoulders, 48 males; 25 females) fulfilled inclusion and exclusion criteria. Patients were classified as group A if operated on with a Bristow-Latarjet procedure (40 patients, 24 males; 16 females) or group B if operated on with an open capsuloplasty (33 patients, 24 males; 9 females). All patients were followed up with physical examination and functional evaluation scores (UCLA, ROWE and WOSI).

RESULTS

In group A, no further episodes of dislocation or subluxation were reported; in group B, one patient (3.3%) reported a new episode of anterior dislocation as a result of a new trauma. No statistical difference in regard of new episodes of shoulder dislocation was found between the two groups (p > 0.05). At physical examination, two patients (5%) of group A and four patients of group B (13.3%) showed a positive apprehension test (p > 0.05); anterior drawer test was positive in six patients (15%) of group A and in nine patients (30%) of group B (p > 0.05). Statistical analysis showed better external rotation in group A (Latarjet group) than in group B. (p = 0.0176). No statistical differences were detected in regard to the scale scores (UCLA, WOSI, Rowe) (p > 0.05). Regarding the return to sport, 29 patients (72.5%) of group A and 18 patients (60%) of group B reported they resumed the same sports activity at the same pre-operative level (p > 0.05).

CONCLUSION

Open capsuloplasty and Bristow-Latarjet procedure are both validated surgical techniques for the treatment of recurrent shoulder anterior instability. We found no statistical difference in terms of recurrent dislocation rates, clinical shoulder stability tests, and scoring scales. The rate of patients returning to sport was similar after both techniques. However, patients with open capsuloplasty reported a significantly lower recovery of external rotation than patients operated via the Latarjet procedure.

Open versus arthroscopic surgical treatment for anterior shoulder dislocation: a comparative systematic review and meta-analysis over the past 20 years

BACKGROUND

The purpose of this study was to perform a meta-analysis comparing open and arthroscopic surgery for the treatment of anterior shoulder instability by analyzing comparative studies during 2 different time intervals during the last 20 years.

METHODS

We conducted a systematic review of MEDLINE, Embase, Scopus, and Google Scholar. Two groups were created by dividing studies according to the year of publication, those published from 1995 to 2004 or from 2005 to 2015. Publication bias and risk of bias were assessed using the Cochrane Collaboration's tools. Heterogeneity was assessed using the I² statistics.

RESULTS

A total of 22 studies (n = 1633) met the eligibility criteria. Comparison of the pooled estimate for all of these studies demonstrated no significant differences (P = .64) in clinical outcomes between open and arthroscopic shoulder stabilization. However, studies published from 1995 through 2004 demonstrated significant differences (P = .015) in recurrence rates favoring open surgery. In contrast, no significant differences (P = .09) in recurrence rates were observed for studies published from 2005 through 2015. The pooled estimate for all studies in both groups demonstrated significant differences (P = .001) in external rotation deficits between open and arthroscopic shoulder stabilization favoring arthroscopic surgery.

CONCLUSION

Despite advances in surgical techniques and devices during the last 20 years, either open or arthroscopic surgical treatment of anterior shoulder dislocation results in similar clinical outcomes. The recurrence rate for arthroscopic surgical stabilization has only marginally decreased, from 16.8% to 14.2%. However, during the earlier decade from 1995 through 2004, patients treated with arthroscopic surgery had twice the risk of recurrence compared with an open procedure.

Long-term outcome of Rockwood capsular shift for recurrent shoulder dislocation

PURPOSE

To review the long-term outcome of Rockwood capsular shift for recurrent shoulder dislocation secondary to trauma.

METHODS

Records of 30 males and 4 females who underwent Rockwood capsular shift for recurrent (≥2 episodes) anterior shoulder dislocation were reviewed. An additional Bankart repair with different techniques was performed in 24 of the patients by 2 different surgeons. The outcome was assessed using the Western Ontario Shoulder Instability Index (WOSI) and the Western Ontario Osteoarthritis of the Shoulder (WOOS) index questionnaires, the modified Rowe score, and the Constant-Murley score. Shoulder range of motion (ROM) was measured. Degenerative joint changes were evaluated on radiographs.

RESULTS

During a mean follow-up of 13 (range, 10-16) years, 6 (18%) patients had a mean of 1.2 recurrent dislocations. Four of the patients reported a traumatic event during recurrent dislocation. Of the 6 patients, 3 had undergone a Bankart lesion repair. Better Rowe and adjusted Constant scores were associated with lower age at first dislocation, at the index surgical procedure, and at follow-up. Four patients developed glenohumeral osteoarthritis: 2 were mild or moderate and 2 were severe and symptomatic. Glenohumeral osteoarthritis was associated with follow-up duration (p=0.03) and poorer Rowe score (p=0.012), adjusted Constant score (p=0.001), and WOOS score (p=0.006).

CONCLUSION

Rockwood capsular shift can preserve shoulder ROM, with rates of recurrent dislocation and degenerative joint changes comparable with other techniques.

Biomechanical Comparison of the Latarjet Procedure with and without Capsular Repair

Background

The purpose of this study was to determine if capsular repair used in conjunction with the Latarjet procedure results in significant alterations in glenohumeral rotational range of motion and translation.

Methods

Glenohumeral rotational range of motion and translation were measured in eight cadaveric shoulders in 90° of abduction in both the scapular and coronal planes under the following four conditions: intact glenoid, 20% bony Bankart lesion, modified Latarjet without capsular repair, and modified Latarjet with capsular repair.

Results

Creation of a 20% bony Bankart lesion led to significant increases in anterior and inferior glenohumeral translation and rotational range of motion (p < 0.005). The Latarjet procedure restored anterior and inferior stability compared to the bony Bankart condition. It also led to significant increases in glenohumeral internal and external rotational range of motion relative to both the intact and bony Bankart conditions (p < 0.05). The capsular repair from the coracoacromial ligament stump to the native capsule did not significantly affect translations relative to the Latarjet condition; however it did cause a significant decrease in external rotation in both the scapular and coronal planes (p < 0.005).

Conclusions

The Latarjet procedure is effective in restoring anteroinferior glenohumeral stability. The addition of a capsular repair does not result in significant added stability; however, it does appear to have the effect of restricting glenohumeral external rotational range of motion relative to the Latarjet procedure performed without capsular repair.

A Meta-Analysis of Arthroscopic versus Open Repair for Treatment of Bankart Lesions in the Shoulder

Background

The optimal treatment for Bankart lesion remains controversial. Therefore, we performed this meta-analysis to compare the clinical outcomes of patients managed with open Bankart repair versus arthroscopic Bankart repair.

Material/Methods

After systematic review of online databases, a total of 11 trials with 1022 subjects were included. The methodological quality of randomized controlled trials (RCTs) was assessed using the PEDro critical appraisal tool, and non-RCTs were evaluated by Newcastle-Ottawa (NO) quality assessment tool. Outcomes of shoulder stability, range of motion (ROM), functional scales, and surgical times were analyzed.

Results

Data synthesis showed significant differences between the two strategies, with regards to stability of the shoulder (P=0.008, RR=0.94, 95% CI: 0.89 to 0.98), and ROM (P<0.001, SMD=−0.47, 95% CI: −0.72 to −0.22).

Conclusions

Open Bankart repair produced a more stable shoulder but had a relatively poor shoulder motion, compared with arthroscopic Bankart repair, for the treatment of Bankart lesion.

Outcomes of arthroscopic anterior shoulder instability in the beach chair versus lateral decubitus position: a systematic review and meta-regression analysis

PURPOSE

This study aimed to systematically review the clinical outcomes and recurrence rates after arthroscopic anterior shoulder stabilization in the beach chair (BC) and lateral decubitus (LD) positions.

METHODS

The authors performed a systematic review of multiple medical databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All English-language literature from 1990 to 2013 reporting clinical outcomes after arthroscopic anterior shoulder stabilization with suture anchors or tacks with a minimum 2-year follow-up period were reviewed by 2 independent reviewers. Data on recurrent instability rate, return to activity/sport, range of motion, and subjective outcome measures were collected. Study methodological quality was evaluated with the Modified Coleman Methodology Score (MCMS) and the Quality Appraisal Tool (QAT). To quantify the structured review of observational data, meta-analytic statistical methods were used.

RESULTS

Sixty-four studies (38 BC position, 26 LD position) met inclusion criteria. A total of 3,668 shoulders were included, with 2,211 of patients in the BC position (average age, 26.7 ± 3.8 years; 84.5% male sex) and 1,457 patients in the LD position (average age, 26.0 ± 3.0 years; 82.7% male sex). The average follow-up was 49.8 ± 29.5 months in the BC group compared with 38.7 ± 23.3 months in the LD group. Average overall recurrent instability rates were 14.65 ± 8.4% in the BC group (range, 0% to 38%) compared with 8.5% ± 7.1% in the LD group (range, 0% to 30%; P = .002). The average postoperative loss in external rotation motion (in abduction) was reported in 19 studies in the BC group and in13 studies in the LD group, with an average loss of 2.4° ± 1.0° and 3.6° ± 2.6° in each group, respectively (P > .05).

CONCLUSIONS

Excellent clinical outcomes with low recurrence rates can be obtained after arthroscopic anterior shoulder stabilization in either the BC or the LD position; however, lower recurrence rates are noted in the LD position. Additional long-term randomized clinical trials comparing these positions are needed to better understand the potential advantages and disadvantages of each position.

LEVEL OF EVIDENCE

Level IV, systematic review of studies with Level I through Level IV evidence.

Return to Play After Open Bankart Repair: A Systematic Review

Background:

Results of open Bankart repair have been well reported. However, less information is available outlining the timetable for return to play (RTP) in athletes after this procedure.

Purpose:

To review the current literature regarding (1) the timetable recommended for athletes to RTP after an open Bankart repair and (2) the objective criteria on which the decision to allow an athlete to RTP is based.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A comprehensive literature search was conducted of all relevant English-language articles using the electronic databases OVID and PubMed between the years 1947 and 2012 to identify open Bankart repair. Two reviewers screened articles for eligibility based on the following criteria: (1) an open Bankart repair, (2) a minimum follow-up of at least 8 months, (3) any report that described the procedure in athletes, and (4) any report that described the time for an athlete to RTP. All relevant data were collected and analyzed with regard to number of patients; mean follow-up; Rowe, Constant, and American Shoulder and Elbow (ASES) scores; redislocation rate; and return-to-sport timing.

Results:

In all, 559 relevant citations were identified, of which 29 articles met the inclusion criteria. The mean follow-up was 51.7 months (range, 8-162 months), and the mean age was 25.9 years (range, 21-31 years). The average Rowe score for all studies was 86.9 (range, 63-90). The average redislocation rate was 5.3%. Twenty-six of 29 studies cited a specific timetable for unrestricted RTP, with an average of 23.2 weeks (range, 12-36 weeks). Only 38% of authors reported sport-specific criteria for return to competition, with the majority allowing return to noncontact sports at 12 to 16 weeks, and the resumption of throwing/contact sports by 24 weeks. Three reports described specific functional parameters for RTP.

Conclusion:

The current review summarized return-to-play guidelines for athletic competition after open Bankart repair. These data may provide general guidelines to aid surgeons when determining the appropriate timetable to allow an athlete to return to unrestricted competition.

Does the "bumper" created during Bankart repair contribute to shoulder stability?

BACKGROUND

The aim of this study was to determine the optimal repair configuration for anterior shoulder instability after a labral tear.

MATERIALS AND METHODS

Nine fresh, frozen shoulders were used. With a 50-N axial force, the humeral head was translated anteriorly, and the translational force was measured. The measurement was performed with the capsule intact, after creating a Bankart lesion, and after the Bankart repair at 5 different positions: glenoid rim, glenoid surface-2 mm (on the glenoid surface 2 mm from the glenoid rim), glenoid surface-5 mm, scapular neck-2 mm (on the scapular neck 2 mm from the glenoid rim), and scapular neck-5 mm. Glenoid rim fixation was done with and without a "bumper." The "bumper" was created by plicating the capsule to form a thickened mass of tissue.

RESULTS

The translational force was restored to the intact level after the glenoid rim fixation. However, there was no significant difference in force after the Bankart repair with and without a "bumper" nor after the glenoid rim fixation and glenoid surface-2 mm. The force significantly decreased after scapular neck-2 mm and scapular neck-5 mm compared with the glenoid rim fixation.

CONCLUSION

The anchor fixation on the glenoid face does not increase the translational force compared with the glenoid rim placement, but the placement on the scapular neck decreases the translational force.

Remplissage repair--new frontiers in the prevention of recurrent shoulder instability: a 2-year follow-up comparative study

BACKGROUND

An engaging Hill-Sachs lesion is a defect of the humeral head, large enough to cause locking of the humeral head against the anterior corner of the glenoid rim when the arm is at 90° of abduction and more than 30° of external rotation.

HYPOTHESIS

When Bankart lesions are associated with engaging Hill-Sachs defects, simultaneous Bankart repair and remplissage provide lower recurrence rates than does Bankart repair alone.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Fifty patients (36 men, 14 women) with combined engaging Hill-Sachs and Bankart lesions were evaluated, before and after arthroscopic management, at a minimum follow-up of 2 years. After imaging and arthroscopic assessment, 25 patients underwent remplissage and Bankart repair, and 25 patients received Bankart repair alone. Patients were evaluated using the UCLA, Constant, and Rowe scores, and range of motion was measured using a goniometer. Postoperatively, all patients underwent magnetic resonance imaging to assess the status of healing of the anterior labrum and whether the tenodesis of the infraspinatus covered the Hill-Sachs defect.

RESULTS

At the last appointment, active forward elevation, external rotation beside the body, internal rotation, and all administered scores were significantly improved compared with baseline assessment, with no statistically significant intergroup differences. A new posttraumatic dislocation occurred in 5 patients, all from the Bankart-only group (20%).

CONCLUSION

Remplissage is a safe, relatively short procedure that allows the surgeon to address large humeral defects with a low postoperative recurrence rate. Humeral head large defects predispose to recurrent instability of the shoulder and deserve surgical management.

Arthroscopic repair for posterior shoulder instability

PURPOSE

The purpose of this study was to evaluate outcomes of a consistent arthroscopic stabilization technique for recurrent posterior instability.

METHODS

Thirty-four consecutive shoulders with symptomatic recurrent posterior instability were treated with arthroscopic repair and evaluated at a mean follow-up of 36 months (range, 12 to 67 months). Two patients were excluded because of prior surgery, leaving 32 for further analysis. The mean age was 21.4 years (range, 15 to 33 years). There were 26 male and 6 female patients, and in 59% the dominant shoulder was affected. A known traumatic injury had occurred in 25 (78%), but only 2 (6%) had a documented dislocation. Arthroscopic repair was performed with the patient in the lateral decubitus position through an anterosuperior 12-o'clock viewing portal. Suture anchor repairs were performed in 30 cases and plication to the intact labrum in 4. A sling and derotation wedge were used for 4 weeks, followed by progressive active range of motion, with weight lifting at 3 months and return to contact sports at 6 months. Of the 34 cases, 22 met the inclusion and exclusion criteria and had complete preoperative and postoperative shoulder outcome scores.

RESULTS

Significant improvement (P = .001) from preoperatively to final follow-up was seen for American Shoulder and Elbow Surgeons scores, from 68 to 93; Simple Shoulder Test scores, from 9.3 to 11.6; and visual analog scale scores, from 3.5 to 0.8. All patients returned to their previous level of athletic activity. Two patients reported postoperative instability; none required reoperation. There were no other postoperative complications.

CONCLUSIONS

This study represents a consecutive series of patients with recurrent posterior instability who underwent arthroscopic posterior stabilization. In this population arthroscopic posterior labral repair and capsular plication provided significant clinical improvement and low rates of recurrent instability and revision surgery.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Neer modification of open Bankart procedure: what are the rates of recurrent instability, functional outcome, and arthritis?

BACKGROUND

Neer modified the Bankart procedure by combining a superoinferior capsular shift with the labral reattachment. The theoretical advantages of the modification were that such a procedure would restore the patient's anatomy and also treat the repeated capsular stretching encountered in anteroinferior instability without limiting external rotation and, thereby reducing the risk of arthritis.

QUESTIONS/PURPOSES

We therefore determined: (1) the rate of recurrent instability after this modification, (2) patient function, and (3) the incidence and stage of glenohumeral osteoarthritis at greater than 2 years followup in patients with traumatic anteroinferior instability.

METHODS

We retrospectively reviewed all 64 patients (average age, 27 years) who had the modified Bankart procedure for recurrent dislocations (n = 39) or subluxation (n = 25) from 1991 to 1997. The labrum was reattached with suture anchors and a superoinferior capsular shift was added. We determined the rate of recurrent instability, Rowe and Walch-Duplay scores and shoulder ROM, and the presence of glenohumeral osteoarthritis (modified Samilson and Prieto classification). The minimum followup was 24 months (median, 40 months; range, 24-120 months).

RESULTS

Recurrent instability occurred in seven of the 64 patients (11%) at an average of 25 months postoperatively (range, 7 days to 6 years); in six patients the recurrence was associated with trauma; five of the six patients underwent reoperation with a Latarjet procedure. Eight additional patients (13%) presented with persistent shoulder apprehension or discomfort. The average Rowe score was 83% (range, 20-100%) and average Walch-Duplay score 83% (range, 15-100%). However, only 36 of 64 (56%) patients could return to the same sport at the same level. The loss of external rotation was 13° compared with the contralateral side. Glenohumeral osteoarthritis incidence increased from 4% preoperatively to 17% postoperatively.

CONCLUSIONS

The open Bankart procedure modified by Neer provided high function scores but a relatively low rate of return to sport and high rate of recurrent instability. Our rate of recurrent instability, similar to that obtained with arthroscopic Bankart procedures, has prompted us to abandon the open procedure.

The effect of open Bristow-Latarjet procedure for anterior shoulder instability: a 10-year study

Operative procedures are the usual treatment for patients with anterior traumatic shoulder instabilities. Soft tissue procedures, Bankart repair, cannot be performed in some patients. They need Bristow-Latarjet one. We decided to determine midterm results of this procedure in almost all types of anterior shoulder instability, even shoulders with Bankart lesion in non-athletic cases. Thirty patients after Bristow-Latarjet procedure from 1997 to 2007 were followed 2-8 years. Clinical outcomes, consisted of muscle strength, range of motion (mean 8.66 degrees decreased in external rotation with arm in neutral position and 18.33 with arm in 90 degrees of abduction), recurrent instability (no relapse), and Rowe score (mean 77.66) showed good to excellent results. We had no screw-related or neurovascular complications. Thirty percent of cases had signs of mild arthropathy. Although Bankart procedure is the preferred method in patients with isolated Bankart lesion, but we can perform Bristow-Latarjet for all types of anterior traumatic shoulder instability in non-athletics cases with acceptable results.

The rationale for an arthroscopic approach to shoulder stabilization

The gold standard of treatment for glenohumeral instability has traditionally been viewed as open shoulder stabilization. With the increased awareness of complex instability patterns and the ability to preoperatively detect concomitant pathology with advanced imaging modalities, an evidence-based shift to an all-arthroscopic approach to shoulder stabilization surgery is occurring. Current data suggest that patients who meet eligibility criteria for arthroscopic stabilization (those without significant bony lesions or significant deformity) can expect equivalent rates of recurrence, better functional outcomes, and less morbidity. Modern arthroscopic techniques using suture anchors and capsular plication have resulted in a significant improvement over previous reports in the orthopaedic literature. An argument is put forth on the benefits of an all-arthroscopic approach to shoulder stabilization in athletes and nonathletes alike based on a review of the current orthopaedic literature comparing the evolved arthroscopic technique with more traditional open methods.

Arthroscopic remplissage with Bankart repair for the treatment of glenohumeral instability with Hill-Sachs defects

PURPOSE

To determine whether arthroscopic remplissage with Bankart repair is an effective treatment strategy for patients with Bankart lesions and large Hill-Sachs defects.

METHODS

Between 2006 and 2008, 20 patients underwent arthroscopic Bankart repair with remplissage for the treatment of recurrent anterior glenohumeral instability and large Hill-Sachs defects. Preoperative imaging in all patients identified avulsion of the anterior inferior glenohumeral ligament with an associated Hill-Sachs defect that involved greater than 25% of the humeral head. Patients were followed up postoperatively with the Western Ontario Shoulder Instability score, the American Shoulder and Elbow Surgeons score, and the Penn Shoulder Score. Recurrent subluxation or dislocation was documented.

RESULTS

There were 15 male patients and 5 female patients. The mean age of the patients was 27.3 years. The mean length of follow-up in this series was 29.2 months (range, 24.3 to 37.7 months). At final follow-up, 3 patients reported recurrence of instability, which spontaneously reduced in all cases. The mean American Shoulder and Elbow Surgeons score was 92.5 (pain, 47.3; function, 45.3). The mean Penn score was 90 of 100 (pain, 27.3 of 30; satisfaction, 8.5 of 10; function, 54.3 of 60). The mean total Western Ontario Shoulder Instability score was 72.74% (mean physical symptom score, 77.10%; mean sports and recreation score, 70.25%; mean lifestyle score, 75%; mean emotions score, 58.50%).

CONCLUSIONS

Using an all-arthroscopic remplissage technique with Bankart repair, we were able to restore function, diminish pain, and yield satisfaction in 85% of the patients in this study. Our results compare favorably with historic controls with similar pathology at early- to intermediate-term follow-up in terms of recurrence.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Evaluation and treatment of shoulder instability

The shoulder joint has a wide range of motion as a result of a complex interplay of soft tissue and bone structures. It is also the most frequently dislocated joint in the body. Shoulder dislocations are generally classified as traumatic and nontraumatic. There are many specific causes, each of which necessitate individualized treatment modalities. Accurate diagnosis requires a careful history and physical examination. Arthroscopic surgery and advances in imaging have expanded our understanding of anatomy and pathology relevant to shoulder instability and its treatment. Surgery is the treatment of choice for recurrent traumatic instability. Surgery may also be indicated in some first-time traumatic dislocations in young contact athletes, whereas rehabilitation is the initial treatment of choice in older patients with initial instability and in those with nontraumatic dislocations. Results of arthroscopic capsulolabral repair now equal those of open capsulolabral repair and have become the surgical treatment of choice for most patients. However, in cases of recurrent instability and significant bone deficiency of either the glenoid or humeral head, open bone reconstructive procedures are often necessary to ensure successful outcomes.

[Unstable shoulder dislocation]

Shoulder dislocations are a frequent event and the severity is often underestimated. A thorough clinical investigation and adapted imaging diagnostics are able to detect age-dependent injury patterns. A biphasic conservative treatment keeping the arm in a neutral to mild external rotation for 3 weeks has proven to be most effective and should be followed by an intensive physiotherapy. Nevertheless, conservative treatment protocols show unacceptable recurrence rates particularly in young men active in sport, therefore, surgical stabilisation is recommended. In the past open procedures were accepted as the gold standard, but today arthroscopic Bankart repair using suture anchors shows comparable recurrence rates. However, the clinical outcome with respect to the shoulder function is much better without compromising the subscapularis muscle.

Fuctional outcome after open and arthroscopic bankart repair for traumatic shoulder instability

Purpose

Both open and arthroscopic Bankart repair are established procedures in the treatment of anterior shoulder instability. While the open procedure is still considered as the "golden standard" functional outcome is supposed to be better in the arthroscopic procedure. The aim of this retrospective study was to compare the functional outcome between open and arthroscopic Bankart repair.

Materials and methods

In 199 patients a Bankart procedure with suture anchors was performed, either arthroscopically in presence of an detached, but not elongated capsulolabral complex (40) or open (159). After a median time of 31 months (12 to 67 months) 174 patients were contacted and agreed to follow-up, 135 after open and 39 after arthroscopic Bankart procedure.

Results

Re-dislocations occurred in 8% after open and 15% after arthroscopic Bankart procedure. After open surgery 4 of the 11 re-dislocations occurred after a new adequate trauma and 1 of the 6 re-dislocations after arthroscopic surgery. Re-dislocations after arthroscopic procedure occured earlier than after open Bankart repair. An external rotation lag of 20° or more was observed more often (16%) after open than after arthroscopic surgery (3%). The Rowe score demonstrated "good" or "excellent" functional results in 87% after open and in 80% patients after arthroscopic treatment.

Conclusion

In this retrospective investigation the open Bankart procedure demonstrated good functional results. The arthroscopic treatment without capsular shift resulted in a better range of motion, but showed a tendency towards more frequently and earlier recurrence of instability. Sensitive patient selection for arthroscopic Bankart repair is recommended especially in patients with more than five dislocations.

Treatment of osseous defects associated with anterior shoulder instability

Bone loss of the glenoid and/or humerus is a common consequence of traumatic anterior shoulder instability and can be a cause of recurrent instability after a Bankart repair. Accurate characterization of the size and location of osseous defects associated with traumatic instability is important when planning treatment. Open or arthroscopic soft tissue repairs are usually sufficient when less than 25% of the width of the glenoid bone has been lost. Bone replacement techniques may be necessary when glenoid bone loss is greater than 25% of the glenoid width. Glenoid bone restoration techniques include the use of a tricortical iliac crest graft or the transfer of the coracoid process to the area of glenoid deficiency. Bone grafting becomes a strong consideration when soft tissue repairs have failed to restore stability. Treatment of these severe defects may be followed by osteoarthritis. The destabilizing effects of anterior glenoid bone defects are compounded by concurrent defects of the posterior-lateral humeral head, commonly known as Hill-Sachs lesions, which can engage the glenoid defect. Large humeral head defects can be treated by transhumeral bone grafting techniques or osteoarticular allograft reconstruction. Prosthetic replacement of the proximal humerus is considered for humeral head defects involving more than 40% of the articular surface. Understanding the importance of humeral and glenoid bone deficiencies may help guide the treatment of recurrent anterior glenohumeral instability.

The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment

PURPOSE

Traumatic anterior instability of the shoulder is a common condition associated with a high recurrence rate in young patients. The role of nonoperative versus operative treatment and the optimal surgical approach for this condition is debated. The purpose of this study was to review the literature for the latest evidence comparing outcomes of treatment for traumatic anterior instability of the shoulder.

METHODS

A systematic review of the literature was performed to identify studies comparing operative versus nonoperative treatment for traumatic anterior shoulder instability and studies comparing open versus arthroscopic stabilization for traumatic anterior shoulder instability.

RESULTS

Surgical treatment was associated with a significantly lower rate of recurrent instability at 2 years of follow-up (7% v 46%) and at longer-term follow-up (10% v 58%) for first-time traumatic anterior shoulder dislocation, all in younger patients. The rates of recurrent instability were roughly equal after arthroscopic stabilization with suture anchors and open stabilization with anchors (open, 8.2%; arthroscopic, 6.4%).

CONCLUSIONS

Rates of recurrent instability after a first-time anterior shoulder dislocation, particularly in young active male patients, are reduced by surgical intervention compared with nonoperative treatment. If surgical treatment is indicated, an arthroscopic approach using suture anchors appears to have similar results in terms of recurrent instability to an open approach using suture anchors.

The results of arthroscopic anterior stabilisation of the shoulder using the bioknotless anchor system

Background

Shoulder instability is a common condition, particularly affecting a young, active population. Open capsulolabral repair is effective in the majority of cases, however arthroscopic techniques, particularly using suture anchors, are being used with increasing success.

Methods

15 patients with shoulder instability were operated on by a single surgeon (VK) using BioKnotless anchors (DePuy Mitek, Raynham, MA). The average length of follow-up was 21 months (17 to 31) with none lost to follow-up. Constant scores in both arms, patient satisfaction, activity levels and recurrence of instability was recorded.

Results

80% of patients were satisfied with their surgery. 1 patient suffered a further dislocation and another had recurrent symptomatic instability. The average constant score returned to 84% of that measured in the opposite (unaffected) shoulder. There were no specific post-operative complications encountered.

Conclusion

In terms of recurrence of symptoms, our results show success rates comparable to other methods of shoulder stabilisation. This technique is safe and surgeons familiar with shoulder arthroscopy will not encounter a steep learning curve. Shoulder function at approximately 2 years post repair was good or excellent in the majority of patients and it was observed that patient satisfaction was correlated more with return to usual activities than recurrence of symptoms.

INTEGRITY OF THE SUBSCAPULARIS TENDON AFTER OPEN SURGERY FOR THE TREATMENT OF ANTERIOR SHOULDER INSTABILITY: A CLINICAL AND RADIOLOGICAL EVALUATION

Objective: To evaluate the integrity of the subscapularis tendon by strength, function and magnetic resonance imaging after deltopectoralis access for anterior shoulder instability. Methods: 20 patients with anterior shoulder instability have been evaluated. Minimum follow-up was 12 months, with a mean of 40 months. Only male patients were included, with a mean of age of 29 years (20 − 42 years). The patients have been submitted to physical examinations of mobility, muscular strength, Belly Test and Gerber Test. The isokinetic strength in internal and external rotation, in angular speeds of 60⁰/s and 180⁰/s, for both shoulders was measured using a dynamometer. In 15 patients magnetic resonance imaging (MRI) was carried out on both shoulders for evaluating the thickness, cross-sectional area and atrophy of the subscapularis muscle. Results: A significant difference was found between torque peaks at the speed of 60⁰/s for internal (p=0.036) and external (p=0.008) rotation. However, at 180⁰/s the opposite happens (internal rotation: p=0.133; external rotation: p=0.393). Subscapularis muscle thickness and area are significantly smaller than the normal side, with a deficit of 19% and 23%, respectively. According to Rowe and UCLA scores, we find excellent and good results for the majority of patients, with a mean of 88 and 31.6 points, respectively. Conclusion: Despite of the good functional results, open surgery can limit strength and reduce the thickness and the cross-sectional area of subscapularis muscle. However, the best results were found in the patients who had the dominant side operated.

The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability

Anterior instability is a difficult clinical problem that is treated by a variety of open and arthroscopic methods with good results. Bankart repair remains a popular option. However, in those situations involving irreparable ligamentous damage or bony deficiency, this technique may be insufficient to stabilize the shoulder. One of the principal methods of open treatment for this problem is the Latarjet procedure, as described in his article in 1954. It has proven to be a durable and reliable method of treatment for anteroinferior instability of the glenohumeral joint. Several authors have reported on the long-term outcomes of this procedure with satisfactory results. There has been no previous description of the Latarjet procedure being performed arthroscopically. We present the first report of a new surgical technique, the arthroscopic Latarjet procedure. This procedure is fully arthroscopic and combines the advantages of the open procedure with those of arthroscopic stabilization. This is a significant step forward in the development of arthroscopic shoulder reconstruction and enables shoulder surgeons to treat all cases of instability arthroscopically.