Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for Recurrent Anterior instability of the shoulder: a meta-analysis

The History and Evolution of the Open Labral Repair with Capsular Shift for Shoulder Instability

PURPOSE OF REVIEW

The purpose of this review is to describe the evolution of the open labral repair with capsular shift, including the current role of this procedure in the treatment of shoulder instability.

RECENT FINDINGS

Currently, a subset of patients - high-level collision/contact sport athletes, patients with significant inferior or multi-directional instability, and individuals with failed arthroscopic Bankart repair without bone loss - may experience benefit from undergoing open Bankart repair with capsular shift. Surgeons performing open stabilization can benefit from instrumentation and anchors developed to assist with arthroscopic techniques. Understanding the history and evolution behind the procedure not only allows the surgeon to appreciate principles behind an arthroscopic approach, but also permits the utilization of an open approach when required by patient pathology and risk factors.

Outcomes of Arthroscopic Latarjet as a Revision Surgery After Failed Arthroscopic Bankart Repair

BACKGROUND

The role of arthroscopic Latarjet as a revision surgery after failed arthroscopic Bankart repair has yet to be established.

PURPOSE

To compare clinical outcomes, recurrences, and complication rates of arthroscopic Latarjet as a revision procedure after failed arthroscopic Bankart repair versus arthroscopic Latarjet as a primary procedure.

DESIGN

Cohort study; Level of evidence, 3.

METHODS

This is a retrospective study of prospectively collected data of patients who were diagnosed with anterior shoulder instability and underwent arthroscopic Latarjet stabilization between 2009 and 2018. Patients were separated into 2 groups depending on whether Latarjet was performed after a previous instability surgery (revision) or as a primary surgery (primary). Rowe score, Western Ontario Shoulder Instability Index (WOSI), Constant-Murley Shoulder Outcome (CMSO) score, and Single Assessment Numeric Evaluation (SANE) were assessed pre- and postoperatively with a minimum 24 months of follow-up. In addition, pre- and postoperative levels of sports activity, dislocations, subluxations, and complications were assessed.

RESULTS

A total of 97 patients (n = 62 revision; n = 35 primary), with a mean age of 31.0 ± 8.8 and 29.4 ± 7.6 years old in the revision and primary Latajet group, respectively, met the inclusion criteria. The mean follow-up in the revision group was 32 months (24-53) and 35.5 months (27.7-42.2) in the primary Latarjet group. No significant differences between groups were observed in Rowe score (revision = 91.4, primary = 94.1; P = .223), CMSO score (revision = 90.7, primary = 94; P = .105), and SANE (revision = 85.8, primary = 87.3; P = .683) postoperatively. However, the postoperative difference in the WOSI score between the revision and primary Latarjet groups was nearly significant (510 ± 334 vs 403 ± 343, respectively; P = .05). Four (6.4%) postoperative dislocations were reported in the revision and 1 (2.8%) in the primary Latarjet group (P = .14). Patients in the revision group had a lower return to the previous level of sports participation (P = .008) and decreased external rotation with the arm by the side compared with the primary Latarjet group (P = .000).

CONCLUSION

Arthroscopic Latarjet as a revision surgery is a reasonable surgical option in failed Bankart repair cases. The decision to perform arthroscopic Latarjet stabilization as a revision surgery should not be influenced by the potential risk of future complications as it provides comparable clinical outcomes to the primary Latarjet procedure with a low postoperative recurrence rate. However, a decreased level of postoperative sports participation and external rotation with the arm by the side can be expected.

Review of Burkhart and DeBeer's (2000) article on traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repair: Where have we taken the concept of glenoid bone loss in 2023?

This classic discusses the original publication by Burkhart and DeBeer "Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repair" published in 2000 in Arthroscopy. At that time, the authors sought to understand the reasons behind the failure of arthroscopic soft tissue repair. Based on their findings, the authors introduced the concept of the inverted pear glenoid and engaging Hill-Sachs lesion which is now part of the orthopedic lexicon. The importance of bony pathologic changes in anterior glenohumeral instability has become so apparent, that it now forms the basis of clinical understanding and underpins treatment algorithms. Since this publication over 20 years ago, the idea of glenohumeral bone loss has been extensively explored and refined. There is no doubt of the importance of structural bone loss yet there is still uncertainty as to the best management of those with subcritical bone loss. The purpose of revisiting this classic article is to look at where we are in understanding recurrent instability and bony deficiency while appreciating how far we have come. This review begins with a detailed summary of the classic article along with a historic perspective. Next, we look at the current evidence as it pertains to the classic article and how modern technology and innovation has advanced our ability to assess and quantify glenohumeral bone loss. We finish with expert commentary on the topic from two current surgeons with a research interest in shoulder instability to offer an insight into how modern surgeons view and address this issue. One of the original authors also reflects on the topic. The findings of this classic study changed the way we think about shoulder instability and opened the doors to an exciting body of research that is still growing today. Future research offers an opportunity for high quality evidence to guide management in the group of patients with subcritical bone loss and we eagerly await the results.

Clinical outcomes following open anterior shoulder stabilization for glenohumeral instability in the young collision athlete

BACKGROUND

Anterior glenohumeral instability occurs most commonly in those aged 15-29, with 72% of individuals younger than 22 years suffering recurrent episodes; collision athletes are at particular risk. In the setting of subcritical glenoid bone loss, arthroscopic Bankart repair is widely used despite concerns of recurrent dislocations when compared with open techniques. Furthermore, indications for bone-block procedures are evolving with the Latarjet procedure being favored amongst recent authors as a primary stabilization method in elite and contact athletes.

OBJECTIVE

To determine the efficacy of open modified Bankart stabilization in treating anterior glenohumeral instability in young collision athletes.

METHODS

This was a retrospective review of outcomes of consecutive patients aged 15-20 years who underwent unilateral or bilateral open stabilization for recurrent anterior glenohumeral instability over a 7-year period (2007-2015). The cohort was selected as recent literature suggests that this is the group with the highest redislocation rate and poorest outcomes. Outcome assessments included redislocation rate, return to sport, pain score, patient-related satisfaction scores, and the Western Ontario Shoulder Instability Index.

RESULTS

A total of 60 patients (55 male: 5 female) of mean age 18 years (range: 15-20 years) were available for follow-up at 7 years. All but 3 were competitive athletes with 18 competing regionally and 9 internationally; rugby union and rugby league represent the most common sports. Fifty-five of 60 (92%) have returned to their desired level of sport with 62% of athletes returning to their previous level of competition sport and 1 retuning at a higher level. The mean postoperative pain score was 2.5/10. The mean time to return to play was 14 months (range: 5-48 months). Eight of 60 shoulders reported redislocation (13%), 7 of these being traumatic dislocations after return to high-impact sporting activities. At 7 years of follow-up, 4 of 60 shoulders (7%) had undergone revision surgery.

CONCLUSION

Young collision athletes represent a challenging cohort of instability patients. This study of open modified Bankart in young collision sport athletes revealed excellent outcomes with 92% return to sport and a low revision rate. The results from this cohort rival those of arthroscopic repair. The open procedure described here in this 7-year series represents a robust, reliable technique that could be considered as an alternative to arthroscopic Bankart due to concern for recurrence, while avoiding potential morbidity and complication of bone-block procedures. There is still a role for the open modified Bankart procedure in treating traumatic anterior instability.

Outcomes and Return to Sport and Work After Open Bankart Repair for Recurrent Shoulder Instability: A Systematic Review

Background:

Open Bankart repair provides surgeons and patients with an alternative solution for managing recurrent instability in young athletes with or without minimal bone loss. Despite many studies that have reported low recurrence rates and good functional outcomes after open Bankart repair, we have limited knowledge about the return to sport and work for high-demand populations.

Purpose:

To assess the return to sport and work for high-demand populations after open Bankart repair for recurrent anterior shoulder instability, outcomes of open Bankart repair with regard to recurrence, and development of osteoarthritic (OA) changes.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

We searched PubMed, EMBASE, Cochrane Library, Scopus, and Google Scholar databases using keywords as well as Medical Subject Headings terms and Emtree using “(Open Bankart OR Bankart surgery) (NOT arthroscopy NOT revision)” for English-language studies. We conducted a systematic review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results:

In total, 11 articles (10 with level 4 and 1 with level 3 evidence) including 563 patients (566 shoulders) were identified. The majority of patients were male (82%), the average age at the time of surgery was 27.4 years, and the mean follow-up was 11.5 years (range, 2.5-29 years). The most common functional score used was the Rowe score (95%) for the reported outcome measures, which showed good to excellent results (mean, 88.5 points). The overall recurrent instability rate, including dislocation and subluxation as a postoperative complication, was 8.5%. A total of 87% of patients were able to return to sport and work postoperatively. Overall, OA changes were reported in 33% of the patients, and the overall revision rate was 1%.

Conclusion:

Open Bankart repair exhibited favorable results, with a low postoperative instability rate. It is a reliable surgical procedure that allows high-demand patients to return to sport and work.

Management of shoulder instability in hypermobility-type Ehlers-Danlos syndrome

Shoulder instability in hypermobile Ehlers-Danlos syndrome can result in lifelong pain and functional disability. Treatment in this population is complicated by the severe degree of instability as well as the underlying abnormalities of the joint connective tissue. Appropriate care for these patients requires a thorough understanding of the natural history of their disease, knowledge of the available treatment options, and certain special considerations. This article reviews the pathoanatomy, recognition, and management of shoulder instability in the patient with hypermobile Ehlers-Danlos syndrome.

The 50 Most-Cited Papers on Bankart Lesions

Purpose

To analyze the 50 most-cited articles pertaining to “Bankart lesions,” also known as anteroinferior labral tears, by means of citation analysis as well as to provide analysis and summary of the origins and trends of research on Bankart lesions.

Methods

Scopus was used to query the literature on Bankart lesions. Included articles were related to Bankart lesions and the indications, risk factors, techniques, and outcomes of arthroscopic and open Bankart repair. The 50 most-cited articles were analyzed in the following areas: year of publication, citations in the most recent year, total citation count, contributing authors, institutions, countries, and journals, article classifications, and level of evidence.

Results

Years of publication ranged from 1938 to 2013. There were 608 total citations in the most recent year. Total citation count was 12,441. Regarding country, journal, and authorship, United States, R. A. Arciero, and Arthroscopy were the highest respective contributors. Rush University had the greatest number of publications. The most common article classification was clinical outcomes. Of 49 clinical articles, the most frequent Level of Evidence was IV. The majority of the top 50 Bankart literature consisted of case series and retrospective studies performed in the United States.

Conclusions

Our findings are consistent with the hypothesis that the 50 most-cited articles about Bankart lesions are predominantly U.S.-based, produced by academic orthopaedic groups, clinical outcomes articles, and of Level IV and V evidence. This list of articles should serve as a reference tool for any orthopaedist looking to review Bankart literature.

A Biomechanical, Cadaveric Evaluation of Single- Versus Double-Row Repair Techniques on Stability of Bony Bankart Lesions

BACKGROUND

Previous studies comparing stability between single- and double-row arthroscopic bony Bankart repair techniques focused only on the measurements of tensile forces on the bony fragment without re-creating a more physiologic testing environment.

PURPOSE

To compare dynamic stability and displacement between single- and double-row arthroscopic repair techniques for acute bony Bankart lesions in a concavity-compression cadaveric model simulating physiologic conditions.

STUDY DESIGN

Controlled laboratory study.

METHODS

Testing was performed on 13 matched pairs of cadaveric glenoids with simulated bony Bankart fractures with a defect width of 25% of the inferior glenoid diameter. Half of the fractures were repaired with a double-row technique, and the contralateral glenoids were repaired with a single-row technique. To determine dynamic biomechanical stability and ultimate step-off of the repairs, a 150-N load and 2000 cycles of internal-external rotation at 1 Hz were applied to specimens to simulate early rehabilitation. Toggle was quantified throughout cycling with a coordinate measuring machine. Three-dimensional spatial measurements were calculated. After cyclic loading, the fracture displacement was measured.

RESULTS

The bony Bankart fragment-glenoid initial step-off was found to be significantly greater (P < .001) for the single-row technique (mean, 896 µm; SD, 282 µm) compared with the double-row technique (mean, 436 µm; SD, 313 µm). The motion toggle was found to be significantly greater (P = .017) for the single-row technique (mean, 994 µm; SD, 711 µm) compared with the double-row technique (mean, 408 µm; SD, 384 µm). The ultimate interface displacement was found to be significantly greater (P = .029) for the single-row technique (mean, 1265 µm; SD, 606 µm) compared with the double-row technique (mean, 795 µm; SD, 398 µm).

CONCLUSION

Using a concavity-compression glenohumeral cadaveric model, we found that the double-row arthroscopic fixation technique for bony Bankart repair resulted in superior stability and decreased displacement during simulated rehabilitation when compared with the single-row repair technique.

CLINICAL RELEVANCE

The findings from this study may help guide surgical decision-making by demonstrating superior biomechanical properties (improved initial step-off, motion toggle, and interface displacement) of the double-row bony Bankart repair technique when compared with single-row fixation. The double-row repair construct demonstrated increased stability of the bony Bankart fragment, which may improve bony Bankart healing.

Significant Changes in the Diagnosis, Injury Severity and Treatment for Anterior Shoulder Instability Over Time in a U.S. Population

Purpose

To report the annual incidence of anterior shoulder instability (ASI) diagnosis, injury severity, and surgical stabilization in a U.S. population.

Methods

An established U.S. geographic database was used to identify patients < 40 years old with diagnoses of ASI from 1994-2016. Medical records were reviewed to obtain patient demographics, histories, imaging results, and surgical details. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 U.S. population. Poisson regression was performed to examine trends by timeline, sex and age.

Results

The study population consisted of 652 patients with ASI and a mean age of 21.5 years (range, 3.6-39.5). Comparing 2015-2016 to 1994-1999, we found an increase in the number of dislocations (from 1.0-1.9; P = 0.016) and total instability events (from 2.3-3.4; P = 0.041) per patient prior to presentation to a physician. There was a trend in increased diagnosis of bony Bankart and/or Hill-Sachs on MRI over time, with these lesions documented in 96% of patients undergoing MRI in 2015-2018 compared to 52.9% in 1994-1999 (P < .001). The use of arthroscopic procedures increased and peaked in 2005-2009 (90% of surgical cases performed). The proportion of open Latarjet procedures increased from 2010-2014 (14%) and 2015-2018 (31%).

Conclusions

The age- and sex- adjusted incidence of ASI diagnosis in a U.S. population from 1994-2016 is comparable to that demonstrated in Canadian and European populations. This study demonstrates an increasing number of instability events prior to surgical evaluation, which may correlate with patients’ more commonly presenting with bone loss and requiring more aggressive surgical treatment or that ASI is being more frequently cared for and documented by present-day orthopedic surgeons.

Level of Evidence

Level III, cross-sectional study.

Assessment and Trends in the Methodological Quality of the Top 50 Most Cited Articles in Shoulder Instability

Background:

Citation counts have often been used as a surrogate for the scholarly impact of a particular study, but they do not necessarily correlate with higher-quality investigations. In recent decades, much of the literature regarding shoulder instability is focused on surgical techniques to correct bone loss and prevent recurrence.

Purpose:

To determine (1) the top 50 most cited articles in shoulder instability and (2) if there is a correlation between the number of citations and level of evidence or methodological quality.

Study Design:

Cross-sectional study.

Methods:

A literature search was performed on both the Scopus and the Web of Science databases to determine the top 50 most cited articles in shoulder instability between 1985 and 2019. The search terms used included “shoulder instability,” “humeral defect,” and “glenoid bone loss.” Methodological scores were calculated using the Modified Coleman Methodology Score (MCMS), Jadad scale, and Methodological Index for Non-Randomized Studies (MINORS) score.

Results:

The mean number of citations and mean citation density were 222.7 ± 123.5 (range, 124-881.5) and 16.0 ± 7.9 (range, 6.9-49.0), respectively. The most common type of study represented was the retrospective case series (evidence level, 4; n = 16; 32%) The overall mean MCMS, Jadad score, and MINORS score were 61.1 ± 10.1, 1.4 ± 0.9, and 16.0 ± 3.0, respectively. There were also no correlations found between mean citations or citation density versus each of the methodological quality scores.

Conclusion:

The list of top 50 most cited articles in shoulder instability comprised studies with low-level evidence and low methodological quality. Higher-quality study methodology does not appear to be a significant factor in whether studies are frequently cited in the literature.

Arthroscopic stabilisation for shoulder instability

Since its first description over 30 years ago arthroscopic stabilisation has evolved. With improvements in knowledge, surgical techniques and materials technology, arthroscopic bankart repair has become the most widely used method for treating patients with symptomatic anterior shoulder instability. These procedures are typically performed in a younger, high demand patient population after a primary dislocation or to treat recurrent instability. A thorough clinical evaluation is required in the clinic setting not only to fully understand the injury pattern but also consider patient expectations prior to embarking on surgery. Diagnostic imaging will aid the clinician in determining the soft tissue pathology as well as assessing bone loss, which facilitates surgical decision-making. Selected patients may benefit from adjunctive procedures such as a remplissage for an "engaging" Hill-sachs lesion. This review will focus on the indications, pre-operative considerations, surgical techniques and outcomes of arthroscopic stabilisation.

Arthroscopic Latarjet: Technique Description and Preliminary Results. Study of the First 30 Cases

Objective  Arthroscopic Latarjet has been performed with the aim to be an accurate technique with a low incidence of complications. The aim of the present study was to briefly describe the technique and to evaluate the shot-term complications following arthroscopic Latarjet procedure to correct anterior shoulder dislocation with glenoid bone loss.

Methods  Retrospective study with 30 subjects with anterior shoulder instability, submitted to arthroscopic Latarjet. Intraoperative and short-term postoperative complications were recorded, as well as the rate of revision surgery.

Results  Five cases had complication (16.7%), and in the last 10 cases no complication occurred. In 1 case (3.3%), it was required to reverse for open surgery due to a fracture of the coracoid process during fixation in the glenoid. No other intraoperative complication occurred. No infection was observed. Two cases (6.7%) evolved with temporary neuropraxia of the musculocutaneous nerve, totally reversed with physiotherapy. With a follow-up from 6 to 26 months, 2 patients (6.7%) required a new intervention for graft/screws removal and release of the joint due to excessive limitation in external rotation. There was no case of recurrence.

Conclusion  Even in an initial learning curve, arthroscopic Latarjet demonstrated a low rate of short-tem complications and was a safe procedure for treating anterior dislocation of the shoulder with glenoid bone loss.

Global Perspectives on Management of Shoulder Instability: Decision Making and Treatment

The glenohumeral joint is prone to instability. Patients with instability should have a physical examination. Imaging studies can provide additional information. Classification schemes that into account soft tissue pathology, neuromuscular control, bone loss, and activity level. An arthroscopic Bankart repair is the mainstay for unidirectional instability. Bone block procedures are indicated for patients with bone loss or a failed attempt at stabilization surgery. The arthroscopic Latarjet is a promising option for these patients. For patients with multidirectional instability, prolonged rehabilitation is indicated, followed by capsular plication or inferior capsular shift if instability is unresponsive to physical therapy.

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.

Management of primary anterior shoulder dislocations: a narrative review

Abstract

The recurrence rate following acute anterior shoulder dislocations is high, particularly in young, active individuals. The purpose of this paper is to provide a narrative overview of the best available evidence and results with regards to diagnostic considerations, comorbidities, position of immobilization, surgical versus conservative management, and time to return to play for the management of primary anterior shoulder dislocations. Three independent reviewers performed literature searches using PubMed, MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Randomized controlled trials and systematic reviews meeting inclusion criteria from 1930 to April 2019 were appraised and discussed with the intent to consolidate the best available evidence with regards to lowering recurrence rates. A majority of studies support early surgical intervention for individuals between 21 and 30 years of age following primary shoulder dislocations, as this group is particularly susceptible to recurrence. Conservative treatment plans favor 1–3 weeks of immobilization in internal rotation, followed by rehabilitation. Surgical methods are associated with longer time to return to play, but lower recurrence rates. Return to play time is best determined on an individualized basis, when subjective and objective function of both shoulders is determined to be symmetric. This paper broadly summarizes the best available evidence for the management of primary anterior shoulder dislocations. There remains a need for randomized studies to determine ideal long-term treatment following conservative or surgical management, as general timelines for returning to play following injury remain vague.

Level of evidence

IV, Narrative Review

Meta-Analysis of Randomized Controlled Trials Involving Anterior Shoulder Instability

Background:

Arthroscopic repair is gaining popularity over open repair for the treatment of bankart lesions. The study aims to evaluate the outcome of arthroscopic repair with open repair in randomised controlled trials conducted comparing the two techniques.

Methods:

We searched the Cochrane library, PubMed and EMBASE up to December 2017 for clinical trials comparing the outcomes of arthroscopic bankart repair with open bankart repair. We used fixed or random effects model depending upon heterogenicity. Dichotomous variables were presented as Risk Ratios (RRs) with 95% Confidence Intervals (CIs), and continuous data were measured as measured differences with 95% CIs.

Result:

Five studies were included, with sample size ranging from 42 to 196. Fixed effect analysis showed that the shoulder was more stable in open repair (RR=0.897, 95% CI: 0.821 to 0.980, P= 0.94) but the loss of external rotation at shoulder joint was also higher in those had open repair (RR=0.325, SMD=-0.411, 95% CI: -1.229 to 0.407). The functional outcome assessed by Rowe score was better in open repair (P=0.325). The operative time was lesser in arthroscopic repair but was not statistically significant (P=0.085).

Conclusion:

Our meta-analysis showed that the use of arthroscopic repair though offers better shoulder movement but the open repair is superior in terms of shoulder stability.

Anterior Shoulder Instability: A Systematic Review of the Quality and Quantity of the Current Literature for Surgical Treatment

Background

Anterior shoulder instability is the most common sequela of shoulder dislocation and can result in repeated dislocations or subluxation of the glenohumeral joint. Anterior shoulder instability can be treated conservatively or surgically with several procedures.

Purpose

To date, arthroscopic Bankart is the most common surgical procedure for the treatment of anterior shoulder instability. No previous studies have compared all anterior shoulder surgical procedures. In this study, the authors performed a systematic review of journal articles describing all surgical procedures for anterior shoulder instability to determine the scientific evidence and level of recommendation.

Study Design

Systematic review; Level of evidence, 4.

Method

A comprehensive literature search was conducted (July 19, 2016) with 4 reputed databases: PubMed, EMBASE, the Cochrane databases, and Web of Science. The articles found in the literature search were screened by 2 reviewers on the basis of their titles, abstracts, and full text. Data were extracted from relevant studies, and potentially relevant records were selected for full-text review. Included articles were classified according to their scientific quality (level of evidence, 1-5). The studies were then combined for each surgical procedure, and a grade of recommendation was assigned for each procedure: grade A, treatment recommendation based on level 1 evidence studies; B, based on level 2 or 3 evidence studies; C, based on level 4 or 5 evidence and could represent conflicting results; or I, insufficient evidence to recommend a treatment. As such, the grade of recommendation provides a summary score for the quality and quantity of available literature to support the surgical procedures reviewed here.

Results

The systematic literature review generated 11,281 articles. After screening, 655 articles were included. Results revealed 31 surgical procedures for shoulder instability following dislocation: 10 surgical procedures were given an A or B recommendation; 11, a C recommendation; and 10, an I recommendation.

Conclusion

This review identified many surgical procedures to treat anterior shoulder instability. Ten of these surgical procedures had an abundant amount of published articles to describe their safety and efficacy. Arthroscopic Bankart and open Bankart were the most commonly reported procedures that cite satisfactory postoperative outcomes and limited complications. Publications on the other surgical procedures were less common. Surgeons should be careful when recommending surgery, and they should choose the appropriate surgical procedure based on evidence-based literature.

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.

ARTHROSCOPIC LATARJET TECHNIQUE COMBINED WITH ENDOBUTTONS: FUNCTIONAL OUTCOMES IN 26 CASES

Objective

The cause of anterior shoulder instability is not fully understood and surgical management remains controversial. The objective of this study was to evaluate the results of patients undergoing arthroscopic Latarjet procedure with endobuttons.

Methods

A retrospective study of 26 patients undergoing arthroscopic Latarjet procedure with endobuttons to treat anterior shoulder instability. Patients with previous glenohumeral instability, failure of Bankart procedure or Instability Severity Index Score (ISIS) greater than or equal to 6, were included. Patients were assessed by: DASH, UCLA, Rowe, Visual Analog Scale (VAS) of pain and Short-Form 36 (SF36) scores. Correct position and consolidation of the graft were evaluated.

Results

Mean age was 31.5 years (16 to 46). Preoperative duration of symptoms was 1.7 years (1 month to 10 years). Mean follow-up was 14.3 (6 to 24) months. Mean postoperative scores were: 10 points in DASH; 1.6 in VAS, where 23 (88%) patients experienced mild pain and 3 (12%) moderate pain; 89 in Rowe; 32 in UCLA and 78 in SF-36. Positioning of the graft was correct in 25 (96%) cases, and was consolidated in 23 (88%). We had two cases of graft fracture (7%) and postoperative migration (7%).

Conclusion

Surgical treatment using arthroscopic Latarjet with endobuttons is safe and effective, producing good functional outcomes in patients. Level of Evidence IV, Case Series.

Traumatic Instability: Treatment Options and Considerations for Recurrent Posttraumatic Instability

Recurrent traumatic glenohumeral instability is a complex problem with multiple variables to consider, but patient demographics, activities, as well as clinical and radiographic findings provide significant information to help choose the best treatment option. Although nonoperative treatment is a viable option for primary glenohumeral instability and in-season instability, recurrent instability exhibits anatomic factors which render nonsurgical treatment limited in scope. A proper patient history, clinical examination, and standard and advanced imaging are necessary in the assessment of patients with recurrent traumatic instability. Age, activity, hypermobility, tissue quality, glenoid and humeral head bone stock, and any prior surgical treatment are factors that must be considered for surgical planning. Open and arthroscopic Bankart repairs are good surgical options when bone loss is not an issue but increasing glenoid or humeral osseous deficiency in this setting frequently warrants additional procedures which address bony insufficiency. Controversy remains concerning the threshold value for glenoid bony deficiency and combined, bipolar defects, but this critical number may be less than previously suspected. Despite this controversy, successful surgical treatment of recurrent glenohumeral instability is possible when properly assessed and the correct surgery applied.

Arthroscopic knotless anterior labral stabilization using labral tape and wide awake anaesthesia-short term results

BACKGROUND

The shoulder is the least constrained of all joints of the body and is more susceptible to injury including dislocation. The rate of recurrent instability following primary stabilization procedure at 10 years of follow-up ranged from 3.4 to 20%. There is a lack of evidence in the literature regarding use of labral tape and anchors for anterior stabilization despite the growing market for this product. We describe the outcomes of 67 patients who underwent knotless arthroscopic anterior stabilisation under awake anaesthesia using 1.5 mm LabralTape with 2.9 mm Pushlock anchors for primary anterior instability by a single surgeon.

METHODS

This was a retrospective analysis of prospectively collected outcome data for adult patients undergoing anterior stabilisation for primary traumatic anterior shoulder instability between 2013 and 2016 at two centres. Patients with > 25% glenoid bone loss, engaging Hill Sach's, and multidirectional instability were excluded. All cases underwent surgery using awake anaesthetic technique. The surgical technique and post-operative physiotherapy was standardized. Outcomes were measured at 6 months and 12 months.

RESULTS

Of the 74 patients in our study, 7 were lost to follow up. Outcomes were measured using the Oxford Instability Shoulder Score (OISS) and clinical assessment including the range of motion. The OISS showed statistically significant improvement from a mean score and standard deviation (SD) of 24.72 ± 2.8 pre-surgery to 43.09 ± 3.5 after the procedure at 12 months with good to excellent outcomes in 66 cases (98.5%). The mean abduction was 134.2 ± 6.32 and external rotation was 72.55 ± 5.42 at 60-90 position at 12 months. We report no failures due to knot slippage or anchor pull-out.

CONCLUSION

Our case series using the above technique has distinct advantages of combining a small non-absorbable implant with flat, braided, and high-strength polyethylene tape. This technique demonstrates superior medium term results to conventional suture knot techniques for labral stabilization thereby validating its use.

Open Bankart repair plus inferior capsular shift versus arthroscopic Bankart repair without augmentations for traumatic anterior shoulder instability: A prospective study

PURPOSE

Arthroscopic treatment of shoulder instability has some advantages (including short surgical time, less morbidity, less postoperative pain, reduced hospitalization time, and decreased risk of complications) compared with open procedures. We performed a prospective study comparing open repair with arthroscopic repair for recurrent anterior shoulder instability. The aim was to clarify the relative effectiveness of open Bankart repair plus inferior capsular shift (OBRICS) and arthroscopic Bankart (AB) repair without augmentations with approximately 5 years of follow-up.

METHODS

We investigated 32 shoulders of 30 patients (24 men and 6 women) undergoing OBRICS (15 shoulders of 17 patients; two patients were bilateral) and AB (15 shoulders of 15 patients). The average follow-up was 5 years and 2.5 months (range: 60-66 months). The clinical evaluation included recurrent instability rate, range of motion, and postoperative rehabilitation. All patients were assessed using the scoring systems of Rowe and the University of California at Los Angeles (UCLA) preoperatively and during the final evaluation.

RESULTS

Recurrent instability rates were significantly different between the OBRICS (0%) and AB (26.6%) groups ( p = 0.022). There were fewer limitations of external rotation (ER), ER at 90° abduction, and horizontal extension for AB than for OBRICS postoperatively ( p < 0.05). The mean Rowe and UCLA scores for both methods were not significantly different at final follow-up.

CONCLUSION

Our data suggest that OBRICS leads to a lower rate of recurrent instability. However, those with AB had fewer ER and horizontal extension limitations.

The effect of subscapularis tenotomy in athletes operated on for recurrent anterior shoulder dislocation

PURPOSE

Some authors consider preservation of the subscapularis tendon as one of the most important elements for a successful long-term outcome in patients operated on with open capsulorrhaphy for recurrent anterior shoulder dislocation. The purpose of this study was to evaluate whether vertical tenotomy of the subscapularis tendon might affect internal rotation strength recovery in patients operated on with open capsulorrhaphy for recurrent anterior shoulder dislocation.

METHODS

Ninety-six patients were retrospectively followed up at a mean of 72.5 months. They underwent clinical evaluation, Rowe and Walch-Duplay scoring scales, the Visual Analog Scale (VAS), and dynamometric measurements (side-to-side) of internal and external rotation, forward elevation, and abduction. All patients were athletes: 25% were practising risk-free sports, 44% contact sports, 14.5% sports with cocking of the arm, and 14.5% high-risk sports activities.

RESULTS

Five (5.2%) recurrences were registered, and all patients returned to pre-operative sports activity. The Rowe score was 98.12, the Walch-Duplay score 92.25, and the VAS score 0.1. Dynamometric assessment showed no significant differences (side-to-side) in internal rotation (p = 0.34), external rotation (p = 0.9), flexion (p = 0.7), and abduction (p = 0.7). Dominant arms showed better results than non-dominant arms (p < 0.01).

CONCLUSION

Complete tenotomy of the subscapularis tendon does not seem to negatively affect internal rotation strength recovery or external rotation movement in athletes.

Pediatric and adolescent anterior shoulder instability: clinical management of first-time dislocators

PURPOSE OF REVIEW

The purpose of this review is to discuss the epidemiology, pathoanatomy, diagnosis, and clinical management of pediatric and adolescent patients following a first-time shoulder dislocation.

RECENT FINDINGS

Shoulder instability is becoming increasingly common as pediatric and adolescent patients engage in earlier organized sports competition. Recommended treatment following a first-time glenohumeral dislocation event in adolescents depends on several factors, but surgical stabilization is becoming more frequently performed. Surgical indications include bony Bankart lesion, ALPSA lesion, bipolar injury (e.g. Hill-Sachs humeral head depression fracture) or off-season injury in an overhead or throwing athlete. Complications following surgical treatment are rare but most commonly are associated with recurrent instability. Young children (eg. open proximal humerus growth plate), individuals averse to surgery, or in-season athletes who accept the risk of redislocation may complete an accelerated rehabilitation program for expedited return to play in the absence of the structural abnormalities listed above.

SUMMARY

Following a first-time dislocation event in pediatric and adolescent patients, a detailed discussion of the risks and benefits of nonoperative versus operative management is critical to match the recommended treatment with the patient's injury pattern, risk factors, and activity goals.

Recurrent Instability After Arthroscopic Bankart Reconstruction: A Systematic Review of Surgical Technical Factors

PURPOSE

Recurrent instability remains of concern after arthroscopic Bankart reconstruction. We evaluated various technical factors including anchor design, anchor material, number of anchors used, and interval closure on risk of recurrent instability after arthroscopic Bankart reconstruction.

METHODS

A systematic review of MEDLINE and Cochrane databases was conducted, following PRISMA guidelines. Extracted data were recorded on a standardized form. Methodological index for non-randomized studies (MINORS) and Newcastle-Ottawa Scale (NOS) were used to assess study quality and risk bias. Because of study heterogeneity and low levels of evidence, meta-analysis was not possible. Pooled weighted means were calculated and individual study evaluation and comparisons (qualitative analysis) were performed for systematic review.

RESULTS

Of 2097 studies identified, 26 met criteria for systematic review. Pooled weighted means revealed 11.4% versus 15% recurrent instability with 3 or more suture anchors versus fewer than 3 anchors, 10.1% versus 7.8% with absorbable versus nonabsorbable suture anchors, respectively, and 8.0% versus 9.4% with knotless versus standard anchors, respectively. Interval closure did not qualitatively decrease recurrent instability or decrease range of motion.

CONCLUSIONS

Our systematic review reveals that despite individual study, and previous systematic reviews pointing to the contrary, the composite contemporary published literature would support no difference in the risk of recurrent instability after arthroscopic Bankart reconstruction with rotator interval closure, differing numbers of anchors used for the repair, use of knotless versus standard anchors, or use of bioabsorbable versus nonabsorbable anchors. We recommend surgeons focus on factors that have been shown to modify the risk factors after arthroscopic Bankart reconstruction, such as patient selection.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Traumatic anterior instability of the shoulder

The shoulder is the most unstable joint in the human body. Traumatic anterior instability of the shoulder is a common condition, which, especially in young patients, is associated with high recurrence rates. The effectiveness of non-surgical treatments when compared to surgical ones is still controversial. The purpose of this study was to review the literature for current concepts and updates regarding the treatment of this condition.

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.

Open shoulder stabilization: current trends and 1-year postoperative complications

Background

Shoulder instability is commonly treated by arthroscopic stabilization. However, open stabilization procedures remain important in management of complex instability. Despite continued use of these procedures, the relative frequency of related complications remains poorly described. This study investigates current trends in open shoulder stabilization and characterizes major postoperative complications.

Methods

PearlDiver, a national insurance database of orthopedic patients, was used to identify open shoulder stabilization procedures from 2007 to 2010. Current Procedural Terminology codes for 4 procedures—Bankart repair, coracoid transfer, and anterior and posterior glenoid bone grafting—were used to track procedural trends. The 1-year postoperative complications were identified and categorized into 5 groups: dislocation treated with closed reduction, closed manipulation under anesthesia, reoperation with arthroscopy, reoperation with open surgery, and others. χ² analysis determined statistical significance.

Results

There were 2678 open shoulder stabilization procedures performed, with a 1-year complication rate of 12.3%. Relative proportion of open Bankart repairs decreased (82.5% to 69.8%), whereas proportion of coracoid transfers increased (7.7% to 19%). Posterior glenoid bone grafting had the highest complication rate (20.7%). Rate of total complications was 9.8% in patients 10-24 years, 13.6% in patients 25-54 years, and 25.9% in patients >55 years.

Conclusions

Based on our patient database sample, a significant decline in the relative use of open Bankart repair was observed. Our analysis indicates that the use of bone transfer procedures was correlated with significantly higher reoperation rates than open Bankart repair, particularly in the older patient cohort. Further studies comparing open stabilization procedures with contemporary arthroscopic techniques are indicated.

Controversies in the Surgical Management of Shoulder Instability: Open vs Arthroscopic Procedures

BACKGROUND

Traumatic anterior instability of the shoulder is a common condition associated with a high recurrence rate in young adults. Operative treatment reduces the risk of recurrence. Several studies have compared arthroscopic and open shoulder instability repair. The purpose of this paper is to perform a review of the literature where both techniques are compared in the repair of the anterior shoulder instability without bone loss.

METHODS

Prior to arthroscopy, recurrent dislocations were managed by open repair. There have been many studies documenting low recurrence rates after open Bankart stabilization. Initially, arthroscopic fixation reported high failure rates.

RESULTS

In the last 20 years, the development of arthroscopic stabilization for recurrent anterior instability has improved failure rates. In comparison with open techniques, arthroscopic procedures have the advantages of decreased morbidity rate, early functional rehabilitation and improved range of motion.

CONCLUSION

The available evidence does not show a statistically significant difference in outcome measures between arthroscopic and open repair for the treatment of recurrent anterior shoulder instability. Given the similar results between the 2 groups, differences in length of hospital stay and cost to the patient and society point to arthroscopic repair as the more judicious treatment approach.

Outcomes After Arthroscopic Bankart Repair: Patients With First-Time Versus Recurrent Dislocations

BACKGROUND

The young athletic population makes up the largest portion of shoulder instability and, when treated nonoperatively, has a recurrent dislocation rate as high as 71%. It is unknown how the outcomes of those who have a recurrent dislocation are affected versus those who have a stabilization procedure after a first-time dislocation.

PURPOSE

To report the postoperative outcomes of patients with first-time dislocations versus patients with recurrent dislocations before surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Current Procedural Terminology codes were used to identify patients who had arthroscopic Bankart repair between 2003 and 2013. A total of 173 eligible patients were identified across 8 fellowship-trained surgical practices. The first phase of the study was a retrospective chart review. Patients were identified as having a first-time dislocation or as having recurrent dislocations when they had >1 dislocation before surgical intervention. The second phase consisted of a survey to record a Simple Shoulder Test score and return to sport and to report postoperative instability and whether patients had further surgery on the shoulder.

RESULTS

A total of 121 patients participated, providing 70% follow-up at an average of 51 months. There were 53 patients in the recurrent dislocation group and 68 in the first-time dislocation group. The postoperative instability rate was 29% in the first-time dislocation group and 62% in the recurrent dislocation group; this difference was significant ( P < .001). The odds of postoperative instability were 4 times higher in the recurrent dislocation group (odds ratio = 4.14). The first-time dislocation group reported a 7% rate of repeat operation to address instability, whereas the recurrent dislocation group reported a rate of 32%; this difference was significant ( P < .001). The odds of needing additional surgery on the index shoulder was 6 times higher in the recurrent dislocation group (odds ratio = 6.01).

CONCLUSION

Patients with first-time dislocations had lower postoperative instability rates and reoperation rates when compared with patients with recurrent dislocations before surgery. Young patients with shoulder instability should be offered early surgical intervention to lower the risk of postoperative instability and reoperation.

Bankart Repair Using Modern Arthroscopic Technique

As technology continues to improve, surgeons must regularly re-evaluate techniques to improve efficacy and outcomes. The Bankart repair for shoulder instability has evolved from open reconstruction to minimally invasive arthroscopic techniques, which have the benefit of less pain and morbidity. This technical description and video present a modern arthroscopic technique for Bankart repair used at our institution with high success in an athletic population.

Recurrent Shoulder Instability in a Young, Active, Military Population and Its Professional Implications

Background:

Shoulder instability is a topic of significant interest within the sports medicine literature, particularly regarding recurrence rates and the ideal treatment indications and techniques. Little has been published specifically addressing the occupational implications of symptomatic recurrent shoulder instability.

Hypothesis:

Previous arthroscopic repair will continue to be a significant predisposing factor for recurrent instability in a young, active population, and that recurrent instability may have a negative effect on college graduation and postgraduate occupational selection.

Study Design:

Case series.

Level of Evidence:

Level 4.

Methods:

We conducted a retrospective review of approved medical waivers for surgical treatment of anterior shoulder dislocation or instability prior to matriculation at the US Military Academy or the US Naval Academy for the graduating classes of 2010 to 2013. Statistical analysis was performed to determine the incidence and risk factors for recurrence and to determine the impact on graduation rate and occupation selection.

Results:

Fifty-nine patients were evaluated; 34% developed recurrent anterior instability. Patients with previous arthroscopic repair had a significantly higher incidence of recurrence (38%, P = 0.044). Recurrent shoulder instability did not significantly affect graduation rates or self-selected occupation (P ≥ 0.05).

Conclusion:

There is a significant rate of recurrent shoulder instability after primary surgical repair, particularly among young, active individuals. In addition, arthroscopic repair resulted in a significantly higher recurrence rate compared with open repair in our population. Surgical repair for shoulder instability should not necessarily preclude young individuals from pursuing (or being considered for) occupations that may place them at greater risk of recurrence.

Clinical Relevance:

The risk of recurrent instability is greater than the rate typically described, which may suggest that some subpopulations are at greater risk than others. A unique data point regarding instability is the effect on occupation selection.

Arthroscopic Bankart repair associated with subscapularis augmentation (ASA) versus open Latarjet to treat recurrent anterior shoulder instability with moderate glenoid bone loss: clinical comparison of two series

PURPOSE

The treatment of chronic anterior shoulder instability with glenoid bone loss is still debated. The purpose of this study is to compare short-term results of two techniques treating chronic shoulder instability with moderate glenoid bone loss: bone block according to open Latarjet-Patte procedure and arthroscopic Bankart repair in association with subscapularis augmentation.

METHODS

Ninety-one patients with moderate anterior glenoid bone loss underwent from 2011 to 2015. From these patients, two groups of 20 individuals each have been selected. The groups were homogeneous in terms of age, gender, dominance and glenoid bone loss. In group A, an open Latarjet procedure has been performed, and in group B, an arthroscopic Bankart repair associated with subscapularis augmentation has been performed. The mean follow-up in group A was 21 months (20-39 months), while in group B was 20 months (15-36 months). QuickDash score, Constant and Rowe shoulder scores, were used for evaluations of results.

RESULTS

The mean preoperative rate of QuickDash score was 3.6 for group A and 4.0 for group B; Rowe Score was 50.0 for group A and 50.0 for group B. Preoperative mean Constant score was 56.2 for Latarjet-Patte and 55.2 for Bankart plus ASA. Postoperative mean QuickDash score was in group A 1.8 and 1.7 in group B; Rowe Score was 89.8 and 91.6; Constant Score was 93.3 and 93.8. No complications related to surgery have been observed for both procedures. Not statistically significant difference was reported between the two groups (p > .05). Postoperatively, the mean deficit of external rotation in ER1 was -9° in group A and -8 in group B; In ER2, the mean deficit was -5° in both groups (p = .0942).

CONCLUSIONS

Arthroscopic subscapularis augmentation of Bankart repair is an effective procedure for the treatment of recurrent anterior shoulder instability with glenoid bone loss without any significant difference in comparison with the well-known open Latarjet procedure.

Prevention and management of post-instability glenohumeral arthropathy

Post-instability arthropathy may commonly develop in high-risk patients with a history of recurrent glenohumeral instability, both with and without surgical stabilization. Classically related to anterior shoulder instability, the incidence and rates of arthritic progression may vary widely. Radiographic arthritic changes may be present in up to two-thirds of patients after primary Bankart repair and 30% after Latarjet procedure, with increasing rates associated with recurrent dislocation history, prominent implant position, non-anatomic reconstruction, and/or lateralized bone graft placement. However, the presence radiographic arthrosis does not predict poor patient-reported function. After exhausting conservative measures, both joint-preserving and arthroplasty surgical options may be considered depending on a combination of patient-specific and anatomic factors. Arthroscopic procedures are optimally indicated for individuals with focal disease and may yield superior symptomatic relief when combined with treatment of combined shoulder pathology. For more advanced secondary arthropathy, total shoulder arthroplasty remains the most reliable option, although the clinical outcomes, wear characteristics, and implant survivorship remains a concern among active, young patients.

A prospective cohort study investigating the effect of generalized joint hypermobility on outcomes after arthroscopic anterior shoulder stabilization

OBJECTIVES

Generalized joint laxity has been proposed as a significant risk factor for failure after arthroscopic anterior shoulder stabilization. The purpose of this study was to prospectively measure joint mobility in patients undergoing arthroscopic anterior shoulder stabilization and to determine whether hypermobility is a risk factor for worse outcomes compared with patients having normal joint mobility.

METHODS

Patients with anterior shoulder instability were prospectively enrolled. Generalized joint hypermobility was measured using the Beighton Hypermobility Score and the Rowe, UCLA, SANE, SST, and WOSI scores were administered and reported as patient outcomes preoperatively and following arthroscopic anterior shoulder stabilization at 6 weeks, 6 months, 12 months, and 24 months postoperatively. Patients were stratified into two groups based on their Beighton Hypermobility Score, with scores ≥ 4/9 indicative of joint hypermobility.

RESULTS

Sixteen patients with joint hypermobility (JH) and 18 non-hypermobile patients (NJH) were enrolled. At baseline, there were no significant differences in demographic characteristics or baseline patient-reported outcomes. Significantly more patients in the NJH group had SLAP tears (n = 10) compared to the JH group (n = 2) (p = .013). At all follow-up times, there were no significant differences between the NJH and JH groups with regard to patient-reported outcome scores (p > .05). In the JH group, 17% of patients reported recurrent instability at two years postoperatively compared to 25% of patients in the NJH group. There was no significant difference in failure rate (p = .67).

CONCLUSION

There was no significant difference in patient-reported outcomes or recurrent instability in patients with versus without joint hypermobility undergoing arthroscopic anterior shoulder stabilization.

Infected shoulder joint with loose Suture Anchor in the joint after Bankart's Repair- A Case Report

Introduction:

The glenoid labrum is frequently torn in traumatic glenohumeral dislocation; arthroscopic repair is the standard method of treatment. The complications associated with this repair are pulling out of metal suture anchors, chondrolysis and joint infection. The infection of joint after arthroscopy is less than 1%. Staphylococcus is most common organism and rarely followed by Pseudomonas aeruginosa. We report a case of infected shoulder with chondrolysis of the joint and pulled out metal suture anchor lying inside the joint after Bankart’s repair.

Case Report:

A 22-year-old gentleman came to us with complaints of shoulder joint pain & gross restriction of movements for one year, with history of intermittent fever and treatment in nearby hospital. He also gives past history of recurrent dislocation of shoulder with last episode 18 months back, which was diagnosed as Bankart’s lesion and arthroscopic Bankart’s repair was done 15 months back. He was evaluated at our institute and suspected to have infection of shoulder joint with pulled out metal suture anchor inside the joint. Arthroscopic removal of suture anchor and debridement of shoulder joint was done, Culture was obtained and culture specific antibiotics were given for six weeks, and significant improvement was observed with this line of treatment. At lyear follow up, the patient was able to perform his daily activities with terminal restriction of range of motion.

Conclusions:

Shoulder joint infection is rare after Bankart’s repair and required a high degree of suspicion. Any foreign materials inside the joint should be taken out & followed with aggressive treatment by debridement, irrigation and culture specific antibiotics. Suppression of joint infection with antibiotics should be avoided specially when there is foreign body inside the joint.

Outcomes of Bankart Repairs Using Modern Arthroscopic Technique in an Athletic Population

PURPOSE

To report a large number of highly active patients who underwent arthroscopic Bankart repair at our institution over the last decade.

METHODS

A retrospective analysis of patients who underwent primary and revision arthroscopic Bankart repairs using bioabsorbable anchors was performed. Outcome measures included recurrence of dislocation, American Shoulder and Elbow Scores (ASES), Rowe, visual analog scale (VAS), return to sports, and satisfaction scores.

RESULTS

A total of 94 shoulders met the inclusion criteria. The recurrence rate was 6/94 (6.4%) at a mean follow-up of 5 years (range, 3 to 8.3). The mean postoperative scores were as follows: ASES = 91.5/100; Rowe = 84.3/100; VAS = 0.8/10; satisfaction = 8.8/10. In those who attempted to return to sports, 82.5% were able to return to the same level of competition. Statistical analyses revealed a significant increase in risk of recurrence among high school and recreational athletes. No recurrences were observed among professional or college-level athletes. No significant difference in recurrence rates was observed in regards to age, time to surgery, type of athlete (collision v limited contact), repair of SLAP lesion, number of anchors, or revision surgery.

CONCLUSIONS

Although several repair techniques exist for traumatic anterior shoulder instability, arthroscopic repair remains a viable option even in a highly active patient population. This study uniquely identified high school and recreational athletes at higher risk for recurrence. This is perhaps due to inferior shoulder development and technique as well as to limited access to postoperative physical therapy.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Comparison of Time to Recurrence of Instability After Open and Arthroscopic Bankart Repair Techniques

Background:

The results of open and arthroscopic instability repairs have been shown to be equivalent in recent literature.

Purpose:

To compare the time to recurrence (TTR) of instability and disease-specific outcome measures in patients undergoing open and arthroscopic Bankart repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients with recurrent traumatic anterior shoulder instability and a Bankart lesion on diagnostic arthroscopy underwent either open Bankart repair (OB) or arthroscopic Bankart and suture capsulorrhaphy (ABSC) using suture anchors. There was a minimum follow-up of 24 months. The primary outcome measures included Western Ontario Shoulder Instability Index (WOSI) score and time to recurrence of instability (dislocation or subluxation). Rowe score, Simple Shoulder Test, Constant score, American Shoulder and Elbow Surgeons (ASES) score, and Short Form–12 (SF-12) score were also compared.

Results:

A total of 82 shoulders in 80 patients (ABSC, n = 58; OB, n = 24) were evaluated at a mean of 39 months postoperatively. There were 4 clinical failures in the OB group (4 dislocations) and 7 clinical failures in the ABSC group (2 dislocations and 5 subluxations; P = .72 vs OB). The mean time to recurrence of postoperative instability was significantly shorter in the ABSC group (12.6 ± 2.7 months) compared with the OB group (34.2 ± 12 months; P = .04). The WOSI score in the OB group (265 ± 48.1) was better but not statistically significantly compared with the ABSC group (449.8 ± 63.8; P = .06).

Conclusion:

The time to recurrence of instability after open Bankart repair is significantly longer compared with arthroscopic Bankart repair.

Clinical Relevance:

Delayed time to recurrence after open Bankart repair suggests that the open technique may be more suited to withstand the high stress and demands of a heavy-duty profession (contact athletes and heavy manual labor).

History of surgical intervention of anterior shoulder instability

BACKGROUND

Anterior glenohumeral instability most commonly affects younger patients and has shown high recurrence rates with nonoperative management. The treatment of anterior glenohumeral instability has undergone significant evolution over the 20th and 21 centuries.

METHODS

This article presents a retrospective comprehensive review of the history of different operative techniques for shoulder stabilization.

RESULTS

Bankart first described an anatomic suture repair of the inferior glenohumeral ligament and anteroinferior labrum in 1923. Multiple surgeons have since described anatomic and nonanatomic repairs, and many of the early principles of shoulder stabilization have remained even as the techniques have changed. Some methods, such as the Magnusson-Stack procedure, Putti-Platt procedure, arthroscopic stapling, and transosseous suture fixation, have been almost completely abandoned. Other strategies, such as the Bankart repair, capsular shift, and remplissage, have persisted for decades and have been adapted for arthroscopic use.

DISCUSSION

The future of anterior shoulder stabilization will continue to evolve with even newer practices, such as the arthroscopic Latarjet transfer. Further research and clinical experience will dictate which future innovations are ultimately embraced.

Arthroscopic treatment of shoulder instability in professional athletes

BACKGROUND

Post-traumatic shoulder instability is a common disease, especially in sportsmen. If inadequately or late treated, it may be responsible for an articular biomechanics alteration, with serious problems. This is much more obvious for professionals athletes, because corporate and market needs force them to a premature return to sport. The purpose of this retrospective study is to evaluate if arthroscopic approach may be better than the open one and allowing a shoulder function rapid recovery, with fast return to sport.

MATERIALS AND METHODS

From January 2003 to January 2014, 46 professional athletes underwent surgical treatment for post traumatic shoulder instability. Two groups were made: 25 athletes treated arthroscopically and 21 treated with open approach. Patients were followed up from 36 to 92 months, according to Rowe Score for Instability and VAS scoring system.

RESULTS

Patients in the open group returned later than the first one to sport. Moreover, pain in postoperative period and during rehabilitation, was lower in the arthroscopic group. There was only one recurrence in the open group.

CONCLUSIONS

Arthroscopic surgical approach appears to be excellent in shoulder instability management, reducing recovery time, allowing a faster return to sport, with less pain, if compared with open surgery.

LEVEL OF EVIDENCE

III, a case control-study.

History of shoulder instability surgery

PURPOSE

The surgical management of shoulder instability is an expanding and increasingly complex area of study within orthopaedics. This article describes the history and evolution of shoulder instability surgery, examining the development of its key principles, the currently accepted concepts and available surgical interventions.

METHODS

A comprehensive review of the available literature was performed using PubMed. The reference lists of reviewed articles were also scrutinised to ensure relevant information was included.

RESULTS

The various types of shoulder instability including anterior, posterior and multidirectional instability are discussed, focussing on the history of surgical management of these topics, the current concepts and the results of available surgical interventions.

CONCLUSIONS

The last century has seen important advancements in the understanding and treatment of shoulder instability. The transition from open to arthroscopic surgery has allowed the discovery of previously unrecognised pathologic entities and facilitated techniques to treat these. Nevertheless, open surgery still produces comparable results in the treatment of many instability-related conditions and is often required in complex or revision cases, particularly in the presence of bone loss. More high-quality research is required to better understand and characterise this spectrum of conditions so that successful evidence-based management algorithms can be developed.

LEVEL OF EVIDENCE

IV.

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.

Operative Management Options for Traumatic Anterior Shoulder Instability in Patients Younger Than 30 Years

Anterior instability of the glenohumeral joint is a relatively common problem in the young population. Identification and treatment is essential to reduce the risk of recurrent instability, whether that is re-dislocation or subluxation events. Non-operative treatment for first-time dislocations was the classic option; however, a relatively high rate of recurrent dislocations has led to earlier operative management in some cases. Surgical treatment through either an open or arthroscopic approach has continued to be an area of research and debate. The decision depends partly on the exact etiology of the instability and the extent of soft tissue or bony deficiency. As arthroscopic techniques and experience improve, surgical procedures for arthroscopic anterior shoulder instability continue to evolve. This review serves as an in-depth overview of the treatment options for traumatic anterior shoulder instability in the patient younger than 30 years, generally focusing on non-rotator cuff-associated etiologies for recurrent instability.

Results of Arthroscopic Bankart Lesion Repair in Patients with Post-Traumatic Anterior Instability of the Shoulder and a Non-Engaging Hill-Sachs Lesion with a Suture Anchor after a Minimum of 6-Year Follow-Up

Background

Shoulder instability is an important clinical problem. Arthroscopic surgery is an established treatment modality in shoulder instability, but it continues to be associated with a high rate of recurrences and complications. The purpose of the study was to analyze late outcomes of arthroscopic repair of Bankart lesions in patients with post-traumatic anterior shoulder instability and non-engaging Hill-Sachs lesion, with special focus on the incidence and causes of recurrences and complications.

Material/Methods

We investigated 92 patients (92 shoulders) who underwent surgery on account of post-traumatic anterior shoulder instability. The duration of follow-up ranged from 6 to 12.5 years (mean: 8.2 years). All patients were operated on in the lateral decubitus position using FASTak 2.8-mm suture anchors (FASTak, Arthrex, Naples, Florida). Treatment outcomes were evaluated using the Rowe and University of California at Los Angeles rating system (UCLA).

Results

According to Rowe scores, there were 71 (81.5%) excellent, 12 (12.6%) good, 5 (5.3%) satisfactory, and 2 (2.1%) poor results. Rowe scores improved in a statistically significant manner (p=0.00) post-surgery, to a mean of 90 (range: 25–100). Treatment outcomes measured as UCLA scores improved in a statistically significant manner (p=0.00), reaching post-operative levels of 12–35 (mean: 33.5). There were 9 recurrences, 1 case of axillary nerve praxia, and 1 case of anchor loosening.

Conclusions

With rigorous criteria for qualifying patients for surgery, arthroscopic treatment of post-traumatic anterior shoulder instability produces good outcomes and low recurrence and complication rates irrespective of the number of previous dislocations, age, or sex.

Effectiveness and safety of arthroscopic versus open Bankart repair for recurrent anterior shoulder dislocation: a meta-analysis of clinical trial data

PURPOSE

To evaluate the effectiveness and safety of arthroscopic and open Bankart repair for recurrent anterior shoulder dislocation using meta-analysis of data from clinical trials.

MATERIALS AND METHODS

Cochrane Register of Controlled Trials, PUBMED and EMBASE were used to search and identify clinical trials that evaluated arthroscopic and open Bankart repair for recurrent anterior shoulder dislocation. Methodological qualities of studies were assessed by Cochrane Collaboration tool for assessing risk of bias and Newcastle-Ottawa Scale. Publication bias was detected using Begg's test and Egger's test.

RESULTS

Sixteen trials involving 827 shoulders were included in the study. Based on Cochrane Collaboration tool for assessing risk of bias, three studies were rated as high quality and one study was rated as moderate quality among the randomized controlled trials. Another twelve case-control studies were rated as high quality based on Newcastle-Ottawa Scale. No significant publication bias was detected by Begg's test or Egger's test. Meta-analysis results indicated that arthroscopic repair has a significantly better recovery rate for external rotation at 90° of abduction, external rotation at side (P > 0.05) and forward flexion. However, arthroscopic repair had higher rates of recurrence and reoperation than open Bankart repair.

CONCLUSION

Meta-analysis of available randomized controlled trials and case-control studies demonstrated that arthroscopic repair and open Bankart repair were similar in safety. Arthroscopic repair resulted in better recovery of range of motion, but recurrence and reoperation rates were higher than open Bankart repair.

Approach to the treatment of primary anterior shoulder dislocation: A review

Glenohumeral joint dislocation is common among younger, active patients. Anterior dislocation is the most common direction of instability following a traumatic event. Due to a high rate of recurrence following primary traumatic anterior shoulder dislocation, an evidence-based approach is necessary to determine the best treatment regime for a patient presenting with this problem. A history, physical examination, and radiographic imaging can help guide treatment recommendations by determining the extent of soft tissue damage following dislocation. Controversies in the treatment of the first-time dislocator include the length and position of immobilization following dislocation, and the role of initial surgical stabilization. This article outlines the treatment options for the first-time glenohumeral dislocator, with an emphasis on the available evidence in the literature. Where applicable, the criteria known as the Strength of Recommendation Taxonomy were used to summarize the strength of evidence available for recommendations.