Minimum 10-year follow-up of arthroscopic intra-articular Bankart repair using bioabsorbable tacks

Patients Have a 15% Redislocation Rate After Arthroscopic Bankart Repair With a Knotless Technique

Purpose

To evaluate the redislocation rate after arthroscopic Bankart repair (ABR) with a standardized knotless anchor technique in a consecutive series of patients with anterior glenohumeral instability.

Methods

Inclusion criteria were patients who underwent ABR by a single surgeon between January 2008 and December 2018 with a minimum follow up of 2 years. We collected data through phone interviews, Western Ontario Shoulder Instability Index, and review of patient records. The primary outcome was redislocation and secondary outcomes were recurrent subluxations, reoperation, postoperative complications, patient satisfaction, and functional outcomes. We also performed survival analysis and risk factor analysis.

Results

Of 88 patients (91 shoulders) who underwent ABR during the inclusion period, 70 patients (73 shoulders) were included (follow-up rate 80%). The mean follow-up was 7.5 years (range 2-12 years). Redislocation occurred in 15% (95% confidence interval [CI] 7.8%-25.4%) of patients at a mean of 41 months after surgery (range 6-115 months). The reoperation rate for recurrent redislocation was 4.1%. Overall, 90.4% reported being currently satisfied with their shoulder and the mean Western Ontario Shoulder Instability Index score at follow-up was 73.8% (range 8.3%-99.9%). Patients with redislocation were younger at primary operation than patients with no redislocation (mean 21 years vs 28 years; P = .023) and adjusted hazard ratio for age was 0.86 (95% CI 0.74-0.99; P = .033). It was more common to have less than 3 anchors in patients with redislocation (P = .024), but adjusted hazard ratio was 4.42 (95% CI 0.93-21.02; P = .061).

Conclusions

The redislocation rate after ABR with a standardized knotless anchor technique in a consecutive series of patients with anterior glenohumeral instability was found to be 15% after a minimum 2-year follow-up (mean 7.5).

Level of Evidence

Level IV, therapeutic case-series.

Mid- to Long-Term Outcomes of Arthroscopic Shoulder Stabilization in Athletes: A Systematic Review

There exists a considerable amount of evidence regarding short-term outcomes of shoulder arthroscopy in athletes; however, mid- to long-term data are limited. Therefore, the purpose of this review is to evaluate studies assessing mid- to long-term outcomes and rates of return to sport in athletes undergoing primary shoulder arthroscopy. A search for the systematic review was performed in PubMed, Scopus, and Embase on 14 March 2023. Study parameters, as well as their respective outcomes, were described in detail and compiled into diagrams. Five studies were included, which contained data on a total of 307 shoulders in patients with mean ages ranging from 20.3 to 26.9 years and mean follow-up times ranging from 6.3 to 14 years. The arthroscopic Bankart repair was the primary surgical intervention performed in all five studies. The overall rate of return to sport was 84% (range, 70-100%) across the studies. The rate of return to sport at pre-injury level was 65.2% (range, 40-82.6%) across four studies. The overall rate of recurrent instability was 17.3%, with redislocation specifically occurring in 13.7% of patients across all studies. The overall rate of revision surgery was 11.1%. Athletes who underwent primary shoulder arthroscopy demonstrated favorable outcomes and a high rate of RTS at a minimum follow-up of 5 years. However, rates of recurrent instability, redislocation, and revision surgery occurred at less than favorable numbers, which emphasizes the importance of proper patient selection when considering candidates for arthroscopic versus open repairs.

Return to Preinjury-Level Sports After Arthroscopic Latarjet for Recurrent Anterior Shoulder Instability in Professional Athletes

Background

The Latarjet procedure is recommended to treat recurrent anterior shoulder instability with glenoid bone loss. Longer return-to-sport (RTS) times have been reported after the open Latarjet when compared with the arthroscopic Latarjet.

Purpose

To assess the clinical outcomes and RTS in athletes who underwent an arthroscopic Latarjet.

Study Design

Case series; Level of evidence, 4.

Methods

This study included 46 professional athletes with recurrent anterior shoulder instability who underwent an arthroscopic Latarjet between 2010 and 2016. Patients were divided by type of sport: noncollision and nonoverhead (n = 22), collision and martial arts (n = 13), and overhead (n = 11). Sport activity was evaluated with the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, Subjective Patient Outcome for Return to Sports score, and RTS time. Clinical results were evaluated by Constant-Murley score, Walch-Duplay score, and range of external and internal rotation. Complication rates, recurrence of shoulder instability, and number of revision procedures were recorded. Correlation tests were used to assess the relationship between measured parameters.

Results

The mean ± SD patient age was 27.1 ± 7.3 years, and the mean follow-up was 50.7 ± 18 months. Overall, 44 patients (95.7%) returned to their previously practiced sports, and 40 (87%) returned to their preinjury levels. The RTS time was 5 ± 1.4 months, with no significant difference among sport types. KJOC and Subjective Patient Outcome for Return to Sports scores were 95.2 ± 5.6 and 9.5 ± 1, respectively. Significant pre- to postoperative improvement was seen on the Constant-Murley score (from 54.3 ± 9.4 to 87.9 ± 8.2; P = .001) and Walch-Duplay score (from 53.7 ± 7.3 to 88.1 ± 10.7; P = .001). Mean postoperative external and internal rotation was 72.8° ± 18.6° and 81.3° ± 11.3°. Procedure-related complications occurred in 10 patients (21.7%); recurrence of shoulder instability was observed in 4 (8.7%); and 4 (8.7%) underwent revision surgery. A worse Walch-Duplay score was significantly associated with longer RTS time (r = -0.39; P = .019) and lower KJOC score (r = 0.29; P = .03).

Conclusion

There was a 95.7% RTS rate after the arthroscopic Latarjet procedure, although the procedure was not free from complications.

Fourteen years of follow-up after first arthroscopic Bankart repair in athletes: functional outcomes and magnetic resonance imaging findings

BACKGROUND

The arthroscopic Bankart procedure is the most performed surgery for shoulder stabilization. Short-term to midterm results are well studied; however, long-term results over 10 years are rare.

PURPOSE

This study evaluates the long-term results and magnetic resonance imaging (MRI) findings in athletes at a mean follow-up of 14 years after an arthroscopic Bankart stabilization as well as risk factors for osteoarthritis.

METHODS

A total of 63 athletes had an arthroscopic Bankart repair between 2001 and 2008, of whom 46 patients (73.0%) participated in the final follow-up. The Constant, Rowe, and Western Ontario Shoulder Instability Index (WOSI) score and the rate of return to sports were evaluated. Glenohumeral osteoarthritis was assessed using the Samilson-Prieto classification. Known risk factors for osteoarthritis were analyzed. MRI findings (bone marrow edema, cysts, and joint effusion) were analyzed.

RESULTS

The average follow-up was 14 years. Assessment was performed on 46 athletes with an average age of 21.6 at the time of surgery. The overall redislocation rate was 21.7%. The Constant score was 96.7, the Rowe score was 83.4, and the Western Ontario Shoulder Instability Index score was 90.7 out of 100. A total of 84.8% of the athletes returned to their initial sports level. Glenohumeral osteoarthritis occurred in 28.1%. Known risk factors for osteoarthritis were confirmed. Further MRI findings were rare.

CONCLUSIONS

Arthroscopic Bankart repair in athletes shows good long-term clinical results. However, this is only in patients without osteoarthritis, which was rare, but was confirmed as a risk factor. We assume that resorption of anchors differs in patients. If it does have an impact on developing arthrosis, this should be confirmed in further studies.

Surgeon variation in glenoid bone reconstruction procedures for shoulder instability

BACKGROUND

Advances in the understanding and management of glenoid bone loss in shoulder instability have led to the development of alternative bony reconstruction techniques to the Latarjet using free bone grafts, but little is known about surgeon adoption of these procedures. This study sought to characterize surgeon variation in the use of glenoid bone reconstruction procedures for shoulder instability and ascertain reasons underlying procedure choice.

METHODS

A 9-question survey was created and distributed to 160 shoulder surgeons members of the PacWest Shoulder and Elbow Society, of whom 65 (41%) responded. The survey asked questions regarding fellowship training, years in practice, surgical volume, preferred methods of glenoid bone reconstruction, and reasons underlying treatment choice.

RESULTS

All surgeons completed a fellowship, with an equal number of sports medicine fellowship-trained (46%) and shoulder and elbow fellowship-trained (46%) physicians. The majority had been in practice for at least 6 years (6-10 years: 25%; >10 years: 59%). Most (78%) performed ≤10 glenoid bony reconstructions per year, and 66% indicated that bony procedures represented <10% of their total annual shoulder instability case volume. The open Latarjet was the preferred primary reconstruction method (69%), followed by open free bone block (FBB) (22%), arthroscopic FBB (8%), and arthroscopic Latarjet (1%). Distal tibia allograft (DTA) was the preferred graft (74%) when performing an FBB procedure, followed by iliac crest autograft (18%), and distal clavicle autograft (6%). The top 5 reasons for preferring Latarjet over FBB were the sling effect (57%), the autologous nature of the graft (37%), its robust clinical evidence (22%), low cost (17%), and availability (11%). The top 5 reasons for choosing an FBB procedure were less anatomic disruption (58%), lower complication rate (21%), restoration of articular cartilage interface (16%), graft versatility (11%), and technical ease (11%). Only 20% of surgeons indicated always performing a bony glenoid reconstruction procedure in the noncontact athlete with less than 20% glenoid bone loss. However, that percentage rose to 62% when considering a contact athlete with the same amount of bone loss.

CONCLUSIONS

Although open Latarjet continues to be the most popular glenoid bony primary reconstruction procedure in shoulder instability, nearly 30% of shoulder surgeons in the western United States have adopted FBB techniques as their preferred treatment modality--with DTA being the most frequently used graft. High-quality comparative clinical effectiveness research is needed to reduce decisional conflict and refine current evidence-based treatment algorithms.

The arthroscopic Bankart operation: a 10-year follow-up study

INTRODUCTION

Traumatic shoulder instability most frequently occurs in young people often during sports events. Currently, the arthroscopic Bankart repair is the therapy of choice in the absence of extensive glenoid bone loss and has proved to be a safe and effective procedure. Nevertheless, we see recurrence of instability-especially if new trauma happens-and further data are needed to guide the right decision-making for these often young patients. The purpose of this study was to determine the long-term outcome 10 years after arthroscopic Bankart operation in terms of satisfaction of the patient, functional result, complications, recurrent instability, and development of osteoarthritis, and to look after possible risk factors for recurrence of instability and statistical proof of these.

MATERIALS AND METHODS

Thirty-nine out of 49 patients underwent physical examination of both shoulders. We could perform a postoperative shoulder a-p X-ray in 28 patients. According to Samilson, [24] the extent of osteoarthritis was measured. The Constant score and the postoperative ROWE score were determined for both shoulders as well as the WOSI Score. In 25 cases, we calculated the ISIS Score.

RESULTS

We could reach out to 89.6% of patients and 79.6% could be physically examined. The vast majority of 95.5% are either very satisfied or satisfied with the result at the time we ended the follow-up. The mean Constant score of 95.5 reflects this result. In contrast to this, we found at the same time in 15.3% ongoing clinical signs of instability of the concerning shoulder, even though 9.1% had to be re-operated for recurrent instability in between the follow-up timeline and we found in the X-rays (57.1% of all patients) in 35.7% at least moderate and in 10.7% severe signs of osteoarthritis. The Constant score but not the ROWE score differed significantly in patients with no or mild compared to those with moderate-to-severe osteoarthritis.

CONCLUSIONS

The arthroscopic Bankart stabilization procedure showed after 10 years to be a very safe operation and to be able to produce a satisfying and functional very good long-term result-reflected by the Constant score. We assume that the extent of osteoarthritis seems to be the determining factor of the very good functional result, even though ongoing instability was present in 15.3% of the patients.

Long-Term Results of Arthroscopic Bankart Repair for Anterior Glenohumeral Instability: Does Associated Postero-inferior Capsulolabral Repair Still Have a Role?

PURPOSE

To compare the outcomes of arthroscopic anterior Bankart repair with and without associated postero-inferior capsulolabral repair as treatment of anterior glenohumeral instabiliy at minimun 10 year follow-up.

METHODS

A retrospective comparative study including patients who underwent arthroscopic anterior Bankart repair to treat anterior glenohumeral instability with glenoid bone-loss < 15% between January 2000 and February 2010 was performed. Outcomes were reported as recurrence rate, type of recurrence (dislocation or subluxation), need for revision surgery, range of motion, complications, and functional status. Outcomes were compared depending on whether a postero-inferior capsulolabral repair was added to the anterior Bankart repair.

RESULTS

70 shoulders [59 males, mean age 28.2 (range 14-56), mean follow-up 146.1 (range 120-208) months] were included. Recurrence occurred in 9 cases (12.8%), including 3 dislocations and 6 subluxations. Revision surgery was needed in 8 (11.4%). Mean Rowe score improved from 29.7 (11.6) preoperatively to 87.1 (12.3) postoperatively. 83.3% returned to previous sports activities. Mean forward flexion changed from 173.5° (19.2) to 168.4º(10.4) (P < 0.01), external rotation from 81.4° (18) to 75.7° (10.5) (P < 0.01), and internal rotation decreased from 66.2% reaching T12 to 14.1% (P < 0.01). Addition of postero-inferior capsulolabral repair did not influence any of the outcomes significantly.

CONCLUSION

Postero-inferior capsulolabral repair added to anterior Bankart repair as treatment of anterior glenohumeral instability in abscence of significant glenoid bone-loss did not influence the outcomes in terms of recurrence, range of motion, return to sports, or functional status, compared to isolated anterior Bankart repair at 12.2 year follow-up.

LEVEL OF EVIDENCE

Level III.

No Difference Between Anchorless and Traditional Suture Anchors in Arthroscopic Bankart Repair: A Clinical Comparison

Background

Shoulder instability and recurrent dislocations are common problems encountered by orthopedic surgeons and are frequently associated with a Bankart lesion. These are classically treated with either open or arthroscopic repair utilizing traditional suture anchors, though anchorless fixation techniques have recently been developed as an alternate fixation method that reduces native bone loss and has comparable pull-out strength.

Methods

A retrospective review was performed at a single institution for patients who underwent Bankart repair from January 2008 through February 2014. American Shoulder and Elbow Surgeons (ASES) questionnaires were mailed to 35 patients with anchorless fixation and 35 age-, gender-, and surgeon-matched patients with traditional suture anchors. Statistical analysis was performed comparing re-dislocation, additional surgery, and ASES scores with statistical significance set at p < 0.05.

Results

Eleven patients in the anchorless implant group and 15 patients in the anchor group completed the questionnaire. The mean follow-up was 4.1 years in the anchorless group and 5.6 years in the anchor group (p=0.04). The number of implants was 4.82 in the anchorless group and 3.87 in the anchor group (p = 0.04). No difference was found in re-dislocation rates (p = 0.80) or additional surgery on the affected shoulder (p = 0.75). ASES scores were found to have no statistical difference (89.89 for the anchorless group versus 85.37 for the anchor group; p = 0.78).

Conclusion

In patients undergoing arthroscopic Bankart lesion repair with traditional anchors compared to anchorless fixation, there appears to be no difference in shoulder re-dislocation rates, recurrent ipsilateral shoulder surgery, or ASES scores.

Cirurgia de Bankart artroscópica: Resultados clínicos com seguimento mínimo de 10 anos

Objective  To evaluate the functional outcome of patients submitted to arthroscopic Bankart repair in the long-term.

Methods  Retrospective evaluation of 41 patients (45 shoulders) operated between 1996 and 2009 followed-up for a mean period of 14.89 years. Functional scores were analyzed by the University of California, Los Angeles (UCLA) and Carter-Rowe scores, physical examination, and analysis of medical records.

Results  The Carter-Rowe score showed an average improvement of 46.11 points, with a final average of 85.89 points, and the UCLA score showed an average improvement of 31.33 points. Ten patients (22.22%) relapsed, with the number of preoperative dislocations being the most correlated factor.

Conclusion  It was demonstrated that the number of preoperative dislocations negatively influenced the failure rate.

Surgical delay for traumatic recurrent shoulder dislocations leads to inferior functional outcomes

BACKGROUND

The effect of time interval between injury and surgery on outcomes of Bankart repair surgery has not been published previously. The purpose of this study was to assess the effect of surgical delay on functional outcomes after arthroscopic Bankart repair.

METHOD

One hundred and five athletes who underwent arthroscopic Bankart repair ± remplissage were enrolled in the study. Patients were divided into 2 groups depending upon the injury to surgery time- < 12 months (n = 19), and ≥12 months (n = 86). Depending upon the number of episodes of dislocation, patients were further categorized into 2 groups- <10 episodes (n = 66) and ≥10 episodes (n = 39). All patients were assessed post-operatively for functional outcomes (Modified Rowe's score, Constant Murley score) and return to sports at a minimum of 2 years of follow-up.

RESULTS

The mean injury to surgery time was 31.7 ± 23.1 months. The average number of episodes of dislocation before surgery were 10 (range 3-50). 49/105 (46.7%) patients returned to sports after a mean post-operative duration of 10.9 months. Athletes operated after a surgical delay of ≥12 months had inferior functional outcomes (Modified Rowe's score-89.5 ± 8.9 vs.77.4 ± 21.4; p = 0.02), lower rate of return to sports (14/19 vs. 35/86; p = 0.02) and higher mean time to return to sports (8.7 ± 1.9 vs. 11.5 ± 2.6; p < 0.05). Similarly, athletes who had ≥10 dislocations before surgery had inferior functional outcomes (Modified Rowe's score-84.5 ± 15.2 vs.72.9 ± 25.6; p = 0.004), lower rate of return to sports (37/66 vs. 12/39; p = 0.02) and higher mean time to return to sports (10.3 ± 2.4 vs. 12.6 ± 2.5; p < 0.05).

CONCLUSION

A delay in surgery (≥12 months) or dislocation episodes of ≥10 are associated with inferior functional outcomes, lower rate of return to sports and higher surgical failure rate.

LEVEL OF EVIDENCE

Level III; Prospective cohort study.

Anterior glenohumeral instability treated with arthroscopic Bankart operation - a retrospective 5-year follow-up study

BACKGROUND

This retrospective study investigated 5-year results of primary arthroscopic operation for anterior glenohumeral instability (AI) with special interest in patients aged<25 years and gender.

HYPOTHESIS

Recurrence of AI is higher in male patients aged<25 years than older patients or females.

PATIENTS AND METHODS

Primary arthroscopic Bankart repair was performed between January 2009 and December 2015 on 156 shoulders [154 patients, 104/156 (67%) males]. The mean follow-up was 5.6 (SD 2.1, range 0.4-8.9) years. Outcome measures, including re-dislocation, fear of dislocation, Western Ontario instability index, Subjective shoulder value and pain Numerical rating scale scores, the number of revision surgeries and satisfaction with the result of surgical treatment, were assessed for 130 shoulders [82/130 (63%) males]. AI recurrence was defined as a dislocation or a fear of such.

RESULTS

The Kaplan-Meier analysis estimates for the cumulative survival of stable shoulders were 28% at 8.8 years for patients aged<25 years (SE 0.4, CI 95% 5.5-7.2) and 53% at 8.9 years for patients aged ≥25 years (SE 0.2, CI 95% 7.2-8.0; p=0.005). The Kaplan-Meier estimates for the cumulative survival of stable shoulders were 50% at 8.9 years for males (SE 0.3, CI 95% 6.8-7.8) and 37% at 8.6 years for females (SE 0.3, CI 95% 6.5-7.7; p=0.8). Mean time to revision was 2.4 (SD 1.7, range 0.4-5.3) years.

DISCUSSION

Recurrence of AI was higher in the patients aged<25 years (p=0.005), but gender was not a risk factor. Re-operation rate due to recurrent AI was 10% in this 5-year follow-up.

LEVEL OF EVIDENCE

III; case-control study.

Outcomes are comparable using free bone block autografts versus allografts for the management of anterior shoulder instability with glenoid bone loss: a systematic review and meta-analysis of "The Non-Latarjet"

PURPOSE

Glenoid augmentation using free bone blocks for anterior shoulder instability has been proposed as an alternative to or bail-out for the Latarjet procedure. The purpose of this investigation was to systematically review and compare outcomes of patients undergoing glenoid augmentation using free bone block autografts versus allografts.

METHODS

A systematic review using PubMed, MEDLINE, Embase, and the Cochrane Library databases was performed in line with the PRISMA statement. Studies reporting outcomes of patients treated with free bone block procedures for anterior shoulder instability with minimum 2-year follow-up were included. Random effects modelling was used to compare patient-reported outcomes, return to sports, recurrent instability, non-instability related complications, and development of arthritis between free bone block autografts and allografts.

RESULTS

Eighteen studies comprising of 623 patients met the inclusion criteria for this investigation. There were six studies reporting on the use of allografts (of these, two used distal tibial, three iliac crest, and one femoral head allograft) in 173 patients and twelve studies utilizing autografts (of these, ten used iliac crest and two used free coracoid autograft) in 450 patients. Mean age was 28.7 ± 4.1 years for the allograft group and 27.8 ± 3.8 years for the autograft group (n.s). Mean follow-up was 98 months in autograft studies and 50.8 months for allograft studies (range 24-444 months, n.s). Overall mean increase in Rowe score was 56.2 with comparable increases between autografts and allografts (n.s). Pooled recurrent instability rates were 3% (95% CI, 1-7%; I² = 77%) and did not differ between the groups (n.s). Arthritic progression was evident in 11% of autografts (95% CI, 2-27%; I² = 90%) and 1% (95% CI, 0-8%; I² = 63%) of allografts (n.s). The overall incidence of non-instability related complications was 5% (95% CI, 2-10%; I² = 81%) and was similar between the groups (n.s). Pooled return to sports rate was 88% (95% CI, 76-96%; I² = 76%).

CONCLUSION

Glenoid augmentation using free bone block autograft or allograft in the setting of recurrent anterior shoulder instability with glenoid bone loss is effective and safe. Outcomes and complication incidence using autografts and allografts were comparable. Due to the high degree of heterogeneity in the data and outcomes reported in available studies, which consist primarily of retrospective case series, future prospective trials investigating long-term outcomes using free bone block autograft versus allograft for anterior shoulder instability with glenoid bone loss are warranted.

LEVEL OF EVIDENCE

IV.

Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long-term results

INTRODUCTION

Arthroscopic stabilisation is a well-recognised surgical technique with a variable rate of failure reported between 0-35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate.

MATERIAL AND METHODS

41 patients that underwent arthroscopic shoulder stabilisation for glenohumeral instability between 2001-2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognised in order to assess possible risk factors.

RESULTS

The overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent/good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery.

CONCLUSION

The arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favourable outcome, with a redislocation rate of 9% and low complication rate.

Arthroscopic nomenclature of capsulolabral appearances in anterior shoulder dislocation

Objectives

To study the intraoperative morphology of the glenoid labrum and capsule in recurrent shoulder dislocation and to study the relationship between the number of dislocations and the changes in the glenoid and labrum.

Methods

Over a period of 18 months, 108 patients with traumatic anterior dislocations were included in the study, of which 102 men and 6 women with mean age of 33.4yrs range from 18 to 45. The patients with bony bankart, other labral lesions, ligamentous laxity, SLAP tear were excluded from the study. All the patients underwent arthroscopic bankart repair. We have classified the morphology of labrum and capsule on their appearance intraoperatively. Labrum is named as Normal, Desiccated or Shredded and Capsule as Normal or Damaged.

Results

Six varieties of appearances were observed. Namely, Normal capsule and Normal labrum (NN), Normal capsule and Desiccated labrum (ND), Normal capsule and Shredded labrum (NS), Damaged capsule and Normal labrum (DN), Damaged capsule and Desiccated labrum(DD), Damaged capsule and Shredded labrum(DS). Among them, DD (33.3%) and DS (29.6%) variety had highest number of dislocations suggesting the labrum and capsule lose normal anatomy with more recurrence of dislocations.

Conclusion

These findings support that reproducing normal anatomy after surgical repair is possible when the intervention is done sooner than later.

Level of evidence

III.

Long-term results of arthroscopic Bankart repairs for anterior instability of the shoulder in patients aged thirty years or older

INTRODUCTION

Bankart repair is a popular treatment for anterior shoulder instability. However, long-term failure rates of arthroscopic Bankart repair remain higher than Latarjet procedures. The purpose of this study was to report long-term results of arthroscopic Bankart repair in patients greater than 30 years old and analyze risk factors of failure following arthroscopic Bankart repair that are independent of younger age.

MATERIALS AND METHODS

Between January 1999 and December 2003, 41 patients aged 30 years or older treated with arthroscopic Bankart repair for anterior shoulder instability were evaluated. Outcome measures included pain (VAS), range of motion, post-operative Walch-Duplay, WOSII scores, complications, failure rate, and risk factors of failure. Failure was defined as recurrent dislocation or subluxation.

RESULTS

At a mean 12-year follow-up (range; 10-15 years), the failure rate of arthroscopic Bankart repair in patients aged 30 years and older was 37%. The mean post-operative Walch-Duplay score was significantly higher in patients who had no recurrence compared to those who had had recurrence of instability (100 versus 90, p=0.02). An ISIS score≥3 (p=0.02), a glenoid bone lesion (p=0.06), and a Hill-Sachs lesion>15% defect (p=0.001) were risk factors for recurrent instability. When considering a modified ISIS score that accounted for bony defects on the glenoid and humeral side, patients with an ISIS score <3 + no glenoid lesion + Hill-Sachs ≤ 15% had a recurrence rate of 0%.

CONCLUSION

The failure rate of arthroscopic Bankart repairs in patients over 30 was higher than previously reported. Specifically, patients with an ISIS >3 and bony glenoid defects and/or Hill-Sachs lesions > 15% may be at higher risk for recurrent instability following an isolated arthroscopic Bankart repair. Alternative stabilization techniques may need to be considered for this subset of patients.

Arthroscopic bankart repair for the management of anterior shoulder instability: Mid- and long- term results

INTRODUCTION

Arthroscopic stabilization is a well-recognized surgical technique with a variable rate of failure reported between 0-35%. The aim of this study was to evaluate the outcome of this technique and our second aim was to identify risk factors that could be associated to recurrence rate.

MATERIAL AND METHODS

41 patients that underwent arthroscopic shoulder stabilization for glenohumeral instability between 2001-2015 were included. Different items such as epidemiologic, recurrence, age at first dislocation, preoperative sport practice, and number of fixation devices used were collected. The results were evaluated using functional scales (WOSI, Rowe y Walch-Duplay) and radiological study was assessed using the Samilson-Prieto score. Data from the medical history were recognized in order to assess possible risk factors.

RESULTS

The overall redislocation rate was 9.4%. The average follow-up was 83 months. The 54.3% of the patients achieved excellent / good results in the functional assessment scales. The range of motion was complete in 90% of the cases. On the radiographs, only 4.88% of the patients present advanced osteoarthritis. It was not possible to identify risk factors related to a worse outcome after surgery.

CONCLUSION

The arthroscopic Bankart repair with suture anchors is considered the gold standard for treatment of anterior glenohumeral instability. The long-term follow-up shows a favorable outcome, with a redislocation rate of 9% and low complication rate.

Arthroscopic Circumferential Labral Repair for Patients With Multidirectional Instability: A Comparative Outcome Study

Background:

Circumferential tears of the glenohumeral labrum are an uncommon injury, comprising 2.4% of all labral lesions. Currently, the clinical outcomes of arthroscopic circumferential labral repair for patients with instability and combined anterior, posterior, and superior labral tears are not well-known.

Hypothesis:

Patients treated with arthroscopic circumferential shoulder labral repairs will have inferior clinical outcomes and higher failure rates compared with patients who have isolated arthroscopic anterior labral repairs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective cohort study was performed to identify patients aged 18 years and older who underwent circumferential arthroscopic stabilization for recurrent instability as compared with an age-matched control group of arthroscopic primary anterior labral repairs. Age at surgery, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form score, Simple Shoulder Test (SST) score, 12-Item Short Form Health Survey (SF-12) score (mental and physical), and overall patient satisfaction with surgery were assessed for each group.

Results:

A total of 35 consecutive patients (36 shoulders) who underwent an arthroscopic 360° circumferential labral repair were compared with a matched group of 31 patients who underwent an isolated arthroscopic anterior labral repair. The mean follow-up period was 34.3 and 56.8 months, respectively. No significant difference was found between the 2 groups for overall satisfaction with the surgery or recurrent instability. At the time of the follow-up survey, 22% of the patients experienced pain and 25% of the patients experienced instability in the circumferential repair group, whereas 15% of the patients experienced some level of pain and 30% of patients experienced a subjective sense of subtle instability in the isolated repair group. The ASES scores were 87.3 in the combined labral repair group and 93.3 in the isolated anterior group (P = .35), SST scores were 10.7 and 11.3 (P = .70), SF-12 mental scores were 54.6 and 56.8 (P = .80), SF-12 physical scores were 53.2 and 54.2 (P = .98), and age at time of the surgery was 26.7 and 24.6 years (P = .33), respectively. There was no difference between the 2 groups in pre- and postoperative range of motion (P > .05).

Conclusion:

There was no difference in shoulder stability and function in patients after 360° combined labral repairs versus anterior labral repair alone. With proper patient selection, patients can expect similar outcomes despite the more extensive surgical procedure and complex postoperative rehabilitation protocol for circumferential repairs.

Results of Arthroscopic Bankart Repair in Recreational Athletes and Laborers: A Retrospective Study With 5 to 14 Years of Follow-up

Background:

Arthroscopic Bankart repair is the most common procedure for anterior shoulder instability management. However, the long-term efficacy of the procedure is questionable, and the results are different among different populations. Few studies have focused on specific populations, such as recreational athletes and laborers.

Hypothesis:

Good to excellent long-term results, with a low recurrence rate, can be achieved using arthroscopic Bankart repair in recreational athletes and laborers suffering from anterior shoulder instability.

Study Design:

Case series; Level of evidence, 4.

Methods:

A specific group of laborers and recreational athletes were included in this study. A total of 52 patients (52 shoulders) with anterior-inferior traumatic shoulder instability underwent arthroscopic Bankart repair and met our strict criteria for study inclusion. The recurrence rate was recorded. Patients were evaluated at a minimum follow-up of 5 years using the American Shoulder and Elbow Surgeons (ASES) score, the Rowe score, the Constant score, and a visual analog scale (VAS) for pain. A radiological evaluation for arthritis was also performed according to the Samilson-Prieto classification.

Results:

The mean follow-up was 105.4 months (range, 65-164 months). Our overall recurrence rate was 11.5% (6/52 patients). All patients were able to return to their previous job status with minimum limitations, and 76.7% of our study population reported returning to their preinjury sporting activities. Postoperatively, all scores were improved, with statistically significant increases from preoperative values (P < .001). At the last radiographic follow-up, 9 patients (18.8%) had mild arthritis, while 2 patients (4.2%) had moderate arthritis.

Conclusion:

Arthroscopic soft tissue Bankart repair may provide good to excellent long-term clinical results with an acceptable recurrence rate in medium-demand patients (recreational athletes and laborers).

Osteointegration of a Biocomposite Suture Anchor After Arthroscopic Shoulder Labral Repair

PURPOSE

To evaluate osteoconductivity of a poly-L-lactide co-glycolide (PLG)-calcium sulfate (CS)-β-tricalcium phosphate (β-TCP) biocomposite suture anchor after arthroscopic shoulder labral repair.

METHODS

The subjects of this study were patients who participated in a clinical trial for acquisition of marketing approval of a PLG-CS-β-TCP biocomposite anchor in Japan. They underwent arthroscopic labral repair using the anchor, and computed tomographic (CT) images of the glenoid were obtained 2 years after surgery. Osteoconductivity at the anchor sites was evaluated with the CT images using the established ossification quality score. Shoulder function scores including the Rowe score and Japanese Shoulder Society shoulder instability score were also assessed 2 years after surgery.

RESULTS

CT images and functional scores were obtained from 37 patients, comprising 29 men and 8 women with a mean age of 29 years (range, 25-33 years) at surgery. A total of 148 anchors were implanted in the 37 shoulders. Osteoconductivity was seen in 133 of 148 anchor sites (90.0%) 2 years after implantation. No significant differences in osteoconductivity were found by anchor diameter or position. The Rowe score significantly improved from 39.9 points (95% confidence interval [CI], 33.8-45.9 points) preoperatively to 96.6 points (95% CI, 95.1-98.1 points) at 2 years postoperatively (P < .001). The Japanese Shoulder Society shoulder instability score also significantly improved, from 63.1 points (95% CI, 58.4-67.7 points) preoperatively to 96.3 points (95% CI, 94.7-97.8 points) at 2 years postoperatively (P < .001).

CONCLUSIONS

Biocomposite suture anchors made of PLG, CS, and β-TCP exhibited some osteoconductivity 2 years after arthroscopic labral repair, as well as good clinical outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Novel and effective arthroscopic extracapsular stabilization technique for anterior shoulder instability-BLS

PURPOSE

Arthroscopic Bankart repair for the treatment of anterior shoulder instability is associated with a high rate of recurrent instability. Extracapsular stabilization of the glenohumeral joint with enhancement of anterior wall soft tissues may be an effective alternative treatment technique. The aim of this study is to retrospectively assess clinical outcomes in the treatment of anterior shoulder instability using a novel technique of anterior extracapsular stabilization-"between glenohumeral ligaments and subscapularis tendon" (BLS).

METHODS

Patients with anterior shoulder instability who underwent surgical treatment with a novel arthroscopic BLS technique between 2008 and 2016 were eligible for inclusion. According to the level of glenoid bone loss, patients were separated into four groups. Group 1 comprised patients with GBL equal to or less than 5%, group 2 patients with GBL 6-10%, group 3 patients with GBL 11-15%, and group 4 patients with GBL > 15%. A positive outcome in this study was defined as full restoration of joint stability. To evaluate clinical results, preoperative range of ER and IR measured in 90 degrees of abduction were compared with ER and IR measured at final follow-up. Additional outcome instruments used consisted of the Constant Score and the Walch-Duplay Score.

RESULTS

A total of 150 patients underwent arthroscopic BLS surgery. During the study period, 50 patients were lost to follow-up and 100 patients were available for final analysis. Mean patient age was 27.5 (± 10.3) years at the time of surgery. Mean duration of follow-up was 82.9 (± 29.4) months. At final assessment, 86 patients (86%) were categorized as having a positive outcome, with full restoration of joint stability. Recurrence of shoulder instability was observed in 14 (14%) patients, including 6 (6%) cases that were associated with major trauma. At final follow-up, the mean Constant Score was 88.2 ± 10.1, compared to 82.9 ± 9.1 preoperatively (p < 0.05). The mean final and mean preoperative Walch-Duplay Scores were 81.5 ± 18.9 and 52.2 ± 11.9, respectively (p < 0.05). There was no statistically significant limitation of external or internal rotation.

CONCLUSIONS

The BLS technique has been shown to be an effective method to anterior shoulder instability in patients without significant glenoid bone loss. It was shown that this technique provides significant improvement in shoulder function without reducing shoulder range of motion.

LEVEL OF EVIDENCE

IV.

Long-term outcomes of the arthroscopic Bankart repair: a systematic review of studies at 10-year follow-up

BACKGROUND

The purpose of this study was to systematically review the evidence in the literature to ascertain the functional outcomes and recurrences rates, as well as subsequent revision rates, following arthroscopic Bankart repair at a minimum of 10 years' follow-up.

METHODS

Two independent reviewers performed a literature search based on Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, using the Embase, MEDLINE, and Cochrane Library databases. Studies were included if they were clinical studies on arthroscopic Bankart repair with a minimum of 10 years' follow-up. Statistical analysis was performed using SPSS software.

RESULTS

Our review found 9 studies including 822 shoulders meeting our inclusion criteria. The majority of patients were male patients (75.5%), the average age was 28.0 years (range, 15-73 years), and the mean follow-up period was 149.4 months. The most commonly used functional outcome score was the Rowe score, with a weighted mean of 87.0. Overall, 77.6% of athletes were able to return to sports postoperatively. The overall rate of recurrent instability was 31.2%, with 16.0% of patients having recurrent dislocations, and the overall revision rate was 17.0%. Evidence of instability arthropathy was found in 59.4% of patients, with 10.5% of patients having moderate to severe arthropathy.

DISCUSSION AND CONCLUSION

Arthroscopic Bankart repair for anterior shoulder instability has been shown to result in excellent long-term functional outcomes despite a relatively high rate of recurrent instability necessitating revision surgery. In addition, the high rate of instability arthropathy is a concern following arthroscopic Bankart repair in the long term.

Arthroscopic glenoid labral lesion repair using all-suture anchor for traumatic anterior shoulder instability: short-term results

BACKGROUND

This study presents the preliminary clinical results of arthroscopic glenoid labral lesion repair using all-suture anchors in the treatment of recurrent traumatic anterior shoulder instability.

METHODS

Seventy patients who underwent arthroscopic shoulder stabilization for traumatic anterior shoulder instability were evaluated in this single center-based retrospective study. Patients with a glenoid defect greater than 20%, off-track engaging Hills-Sachs lesion, multidirectional instability, and generalized ligamentous laxity were excluded. The 62 included patients treated with arthroscopic glenoid labral lesion repair using all-suture anchors were evaluated. The Rowe and Constant scores were used to assess the results.

RESULTS

We evaluated 62 patients with a mean age of 26.7 ± 12 years. The mean Rowe and Constant scores were 35 ± 7.2 and 65 ± 6.3, respectively, preoperatively and increased to 93.6 ± 5.3 and 92 ± 4.3, respectively, postoperatively at the mean follow-up of 28.8 months (range, 24-48 months) (P < .001). The redislocation rate was 8.1%. Of the patients, 91.9% had good to excellent clinical scores. Younger age and contact sports were associated with a higher risk of recurrent dislocation (P = .012 and P = .041, respectively). The postoperative functional results were not significantly correlated with the findings concerning the number of dislocations, time until surgery, degree of anterior translation, and number of anchors.

CONCLUSION

The use of all-suture anchors for arthroscopic glenoid labral lesion repair for the treatment of recurrent traumatic anterior shoulder instability yields satisfactory clinical results and is a safe and effective option.

Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older

BACKGROUND

The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization.

METHODS

A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations.

RESULTS

Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients.

CONCLUSIONS

The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury.

Curved-guide system is useful in achieving optimized trajectory for the most inferior suture anchor during arthroscopic Bankart repair

BACKGROUND

A curved-drill guide system was recently introduced to achieve a better trajectory for a low anteroinferior anchor during arthroscopic Bankart repair. However, the clinical performance of such a device remains unclear. The purpose of this study was to evaluate the trajectory and position of the low anteroinferior suture anchor with use of the curved-guide system in clinical cases.

METHODS

We enrolled 41 cases of arthroscopic Bankart repair in this study. Of these cases, 9 were repaired using the curved drill guide whereas 32 were repaired using a conventional straight guide. Postoperative computed tomography scans were obtained, and 3-dimensional models of the scapula were reconstructed. Notable perforations of the opposite cortex by the most inferior anchors were recorded. The clock-face angle, insertion angle, and insertion distance were measured.

RESULTS

The anchor perforation rate in the curved-guide group (11%) was significantly lower than that in the straight-guide group (56%) (P = .02). The insertion distance in the curved-guide group was significantly shorter than that in the straight-guide group (4.0 ± 1.6 mm vs. 7.0 ± 2.4 mm, P < .01). The clock-face angle and insertion angle were significantly greater in the perforated straight-guide group than in the nonperforated groups. The percentage of anchors in the absolute safe zone (clock-face angle > 135° and < 165° and insertion angle < 100°), where no anchors perforated, was greater in the curved-guide group than the straight-guide group.

CONCLUSION

Compared with the conventional straight guide, the curved-guide system provides better placement of the most inferior suture anchor during arthroscopic Bankart repair.

Variability of Reporting Recurrence After Arthroscopic Bankart Repair: A Call for a Standardized Study Design

Background

High recurrence rates have been reported after anterior shoulder dislocations, regardless of the treatment utilized. However, the definition of recurrent instability has been inconsistent, making a comparison between studies difficult.

Purpose

To report on the nature with which the rate of recurrent instability is reported after arthroscopic Bankart repair, across all levels of evidence, and to analyze factors that may affect the reported rate of recurrence.

Study Design

Systematic review; Level of evidence, 4.

Methods

A systematic review of the literature was performed by searching PubMed, the Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov for studies published within the dates of January 2008 and September 2018. Studies in English that reported on the recurrence of instability after arthroscopic Bankart repair for anterior shoulder instability were considered for inclusion in this review. A meta-regression was performed to test for a linear association between the reported recurrence rate and several continuous covariates, including mean age at surgery, mean length of follow-up, attrition rate (loss to follow-up percentage), and percentage of male patients.

Results

A trim-and-fill meta-analysis yielded an estimated overall recurrence rate of 17.4% (95% CI, 14.3%-20.9%). There was a significant difference in the recurrence rate depending on the level of evidence (Q(3) = 10.98; P = .012). Significant associations were found with the recurrence rate through the meta-regression, including a negative association with mean age (P = .009), a positive association with mean follow-up time (P = .002), and a positive association with attrition rate (P = .035).

Conclusion

A call for standardization is necessary for reporting outcomes of anterior instability after arthroscopic Bankart repair, especially with regard to the reporting of recurrence/failure rates, with careful consideration of the effects that may occur from patient demographics and study design. With no current recommendations for deeming failure, we suggest that all forms of instability be accounted for when determining a failed treatment procedure, with future studies placing an emphasis on greater control of the study design.

Long-term clinical outcome of arthroscopic Bankart repair with suture anchors

BACKGROUND

The most common surgical technique in traumatic anterior shoulder instability is the arthroscopic Bankart repair, which has excellent short-term results. The long-term results of the arthroscopic Bankart repair are less frequently studied, with a high recurrence rate of 23% to 35%. The aim of this study was to evaluate the medium-term to long-term results of arthroscopic Bankart repair using suture anchors and to identify specific risk factors for recurrent instability.

METHODS

Included were 147 patients after traumatic anterior shoulder dislocation who underwent an arthroscopic Bankart repair. The primary outcome was recurrent instability, defined as dislocation or subluxation as perceived by the patients. The secondary outcome was subjective shoulder stability and function as well as quality of life, evaluated using the Western Ontario Shoulder Instability Index, the Simple Shoulder Test, and the 12-Item Short Form Health Survey. Prognostic factors for recurrent instability were analyzed.

RESULTS

Recurrent instability occurred in 22% of patients with a mean follow-up of 6.3 years. Survival at 5 and 10 years without recurrent instability was 79% and 78%, respectively (95% confidence interval, 72%-85% and 71%-85%, respectively). The Western Ontario Shoulder Instability Index score, the Simple Shoulder Test score, and the 12-item Short Form Physical Component Summary improved significantly in the nonrecurrence group (P < .001, P = .004, and P = .002, respectively). Younger age and use of fewer than 3 anchors were associated with a higher risk of recurrent dislocation (P = .008 and P = .039, respectively).

CONCLUSION

We found an overall recurrent instability rate of 22% (dislocation or subluxation). Good long-term results were observed after arthroscopic Bankart repair in patients older than 20 years with 3 or more suture anchors used.

Impact of Remplissage on Global Shoulder Outcome: A Long-Term Comparative Study

PURPOSE

To evaluate the global function of patients treated by arthroscopic shoulder stabilization with or without remplissage at a minimum of 10 years of follow-up.

MATERIALS

The inclusion criteria were existence of a recurrent anterior shoulder dislocation, with or without a Hill-Sachs lesion. The exclusion criteria were prior shoulder stabilization surgery and patients with a glenoid lesion that had been stabilized using the Latarjet procedure. Included patients with a Hill-Sachs lesion underwent surgical remplissage, and the others had Bankart repair only. The main criterion for failure was recurrence of instability or apprehension. The Rowe score and the Walch-Duplay score were used to assess shoulder function before surgery and 10 years afterward, in clinical reviews or telephone interviews.

RESULTS

Seventy-nine patients underwent surgical Bankart repair with or without remplissage between November 2004 and January 2008 and were followed up for a mean duration of 128 months (range, 120-150); 12 patients were lost to follow-up, and 39 patients had Bankart stabilization only: the mean Instability Severity Index Score was 2.3 (range, 0-6). Three patients had recurrence with new dislocation, and 8 patients had apprehension. The Rowe score progressed from 54.3 (range, 25-65) to 83.8 (range, 70-100; P < .01), and the Walch-Duplay score rose from 46.8 (range, 25-75) to 85.6 (range 70-100; P < .01). Twenty-eight patients had arthroscopic Bankart repair + remplissage; the mean Instability Severity Index Score was 1.8 (range, 1-4). There was no recurrence, and no patient had apprehension. The Rowe score progressed from 51.8 (range, 20-65) to 92.3 (range, 70-100; P < .01), and the Walch-Duplay score rose from 58.7 (range, 30-75) to 91.4 (range, 70-100; P < .01). Functional scores in the second group were statistically significant better than in the first one.

CONCLUSIONS

Bankart repair combined with remplissage seems to be an effective method for restoring joint stability in patients with recurrent anterior shoulder dislocation with an associated Hill-Sachs lesion at a minimum of 10 years of follow-up. This technique appears to deliver better functional results than Bankart repair only, showing better scores for mobility and stability in the remplissage group. Limitations (pain and restriction of motion) reported in literature at short-term follow-up for this technical procedure do not seem to be anymore an issue at long-term follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

[Recurrent instability and instability arthropathy]

Capsulolabral reconstruction (Bankart repair) is recommended as the first line treatment in young and functionally demanding active patients with anteroinferior shoulder instability, due to the high tendency to recurrent dislocation. This has become established both for arthroscopic and open primary shoulder stabilization with good clinical outcome; nevertheless, recurrence of dislocation is reported in up to 25% of patients. Risk factors for failed surgery are patient (e.g. young age, male gender and contact sports) and surgery (e.g. primarily underestimated glenoid bone loss, Hill-Sachs lesion, non-treatment of bipolar defects or malpositioned anchors) related. In the management of recurrent instability, it is necessary to carry out a thorough clinical investigation in addition to extended diagnostics with X‑ray and computed tomography. A second Bankart repair is only indicated in patients with low demands and without any glenoid bone loss. In the majority of patients, bony augmentation of the glenoid is necessary and realized by coracoid or iliac crest bone block transfer. The Latarjet procedure is biomechanically advantageous due to the additional sling effect of the conjoined tendons and both techniques show good clinical outcomes and a low recurrence rate. Furthermore, engaging Hill-Sachs lesions also require additional treatment. Remplissage of the infraspinatus muscle, iliac crest bone block transfer and partial joint replacement are viable options. A final consensus for treatment of Hill-Sachs lesions has yet to be defined. Dislocation arthropathy is an underestimated complication as a result of frequent recurrent dislocations. After development of dislocation arthropathy, patients reported a painful restriction of range of motion rather than instability. Arthroscopic arthrolysis and comprehensive arthroscopic management (CAM procedure) are possible joint-preserving treatment options.

Long-term, Prospective, Multicenter Study of Isolated Bankart Repair for a Patient Selection Method Based on the Instability Severity Index Score

BACKGROUND

An isolated arthroscopic Bankart repair carries a high mid- and long-term risk of recurring instability. Preoperative patient selection based on the Instability Severity Index Score should improve outcomes.

PURPOSE

To report the overall long-term recurrence rate for isolated Bankart repair, investigate the predictive factors for recurrence, analyze time to recurrence, and determine a quantitative cutoff point for recurrence in terms of Instability Severity Index Score.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

This was a prospective multicenter study. Inclusion criteria were recurring anterior instability and an Instability Severity Index Score of 4 or less. Of the 125 patients included, 20 patients had a score of 0, 31 patients scored 1, 29 patients scored 2, 34 patients scored 3, and 11 patients scored 4. All centers used the same arthroscopic technique and rehabilitation protocol. Follow-up data were collected at 3, 6, 12, and 24 months and 3 and 9 years. The primary endpoint was recurrence of instability (total or partial dislocation). The statistical analysis was performed by use of the software package SAS 9.4.

RESULTS

We initially identified 328 patients, of whom 125 patients were prospectively included. The main reason for excluding the 202 patients was the presence of bony lesions, which carry 2 points each in the Instability Severity Index Score (humeral head notch and/or glenoid lesion visible on standard radiographs). Of the 125 eligible patients, 73% were athletes and 22.5% competitors; 16% were lost at the last follow-up. At the endpoint, 23% had experienced a recurrence after a mean interval of 35 months (range, 5.5-103 months). No statistical differences were found between patients with and without bony lesions in the overall group of 125 patients or in the subgroup with an Instability Severity Index Score of 3 or 4 points ( P = .4). According to univariate analysis, the only predictive factor for recurrence was age less than 20 years at the time of surgery, with a 42% rate of recurrence in this group ( P = .03). Multivariate analysis showed that the Instability Severity Index Score was the only predictive factor with a quantitative cutoff point (namely, a score of ≤2 points) that was statistically associated with a decreased long term recurrence rate ( P = .02). The recurrence rate was 10% for a preoperative Instability Severity Index Score of 2 or less compared with 35.6% for a score of 3 or 4. The survival curves demonstrated no new dislocations after year 4 for patients with an Instability Severity Index Score of up to 2 points.

CONCLUSION

In a preselected population, mainly without bony lesions, the Instability Severity Index Score cutoff value that provides an acceptable recurrence rate at 9 years after isolated Bankart repair is 2 out of 10.

Long-Term Results of a Monocentric Series of Soldiers After Latarjet Procedure for Anterior Shoulder Instability. Implications for the Assessment of Soldiers' Medical Ability

Introduction

Stabilizing surgery of the shoulder with a coracoid graft according to Latarjet is a recognized surgical treatment for anterior instability of the shoulder. This pathology frequently affects soldiers. Postoperatively, the potential risk of recurrence or of secondary shoulder arthritis can limit the practitioner in their ability assessment. The aim of this study is to analyze the long-term outcomes of this surgery in a military population, in order to assess the possible implications for French soldiers' medical ability.

Material and Methods

Twenty soldiers operated on the shoulder by Latarjet procedure by the same surgeon were retrospectively reviewed after more than 15 yr. All of them did regular physical activity for leisure or competitions. None had preoperative osteoarthritis injuries. The number of dislocation recurrences, the functional score, and the rate of radiographic osteoarthritis were assessed.

Results

After more than 16.3 yr (extremes: 15-24 yr), none displayed a dislocation recurrence. The average Rowe's score was 91.8 ± 9.9. The average subjective shoulder value was 89.2 ± 9.7. All patients had resumed sport. Three of them developed level 1 or 2 radiological signs of osteoarthritis according to Samilson. No level 3 or 4 osteoarthritis was found. Among all the patients, 14 still did regular physical activity.

Discussion

In view of our results and of those from the literature, the results of treatment for anterior shoulder instability with the Latarjet procedure are good, even very good in the long term. These data must be considered to favor this procedure for soldiers with shoulder instability and from a medico-administrative viewpoint for military patients in order to pursue their careers without any job restrictions.

The arthroscopic Bankart repair procedure enables complete quantitative labrum restoration in long-term assessments

PURPOSE

The restoration of the labrum complex and the influence on secondary osteoarthritis after arthroscopic Bankart repair on magnetic resonance imaging (MRI) remain unclear.

METHODS

Twenty-one patients were retrospectively followed after unilateral primary arthroscopic Bankart repair with knot-tying suture anchors (8.8 ± 2.5 years after surgery, age 25.3 ± 6.3 years). Bilateral structural MRI was performed to assess labrum-glenoid restoration by measurements of the labrum slope angle, height index, and labrum interior morphology according to the Randelli classification. Osteoarthritic status was bilaterally assessed by a modified assessment based on the Samilson-Prieto classification.

RESULTS

MRI assessment revealed full labrum-glenoid complex restoration with equivalent parameters for anterior slope angle (mean ± SD: 21.3° ± 2.6° after Bankart repair vs. 21.9° ± 2.6° control) and height index (2.34 ± 0.4 vs. 2.44 ± 0.4), as well as the inferior slope angle (23.1° ± 2.9° vs. 23.3° ± 2.1°) and height index (2.21 ± 0.3 vs. 2.21 ± 0.3) (all n.s.). The labrum morphology showed only for the anterior labrum significant alterations (1.4 ± 0.9 vs. 0.6 ± 0.7, p < 0.05), the inferior labrum occurred similarly (1.3 ± 0.8 vs. 0.8 ± 0.5, n.s.). Osteoarthritic changes were significantly increased after Bankart repair compared to the uninjured shoulder (4.8 ± 5.1 mm vs. 2.5 ± 1.0 mm; p < 0.05), with a significant correlation of osteoarthritis status between both shoulders (p < 0.05). Scores generally decreased after Bankart repair (constant 84.6 ± 9.5 vs. 94.5 ± 4.9 control, p < 0.05; Rowe 84.5 ± 6.5 vs. 96.2 ± 4.2, p < 0.05; Walch-Duplay 82.4 ± 7.0 vs. 94.3 ± 4.0, p < 0.05) with a strong correlation with osteoarthritis status (p < 0.05).

CONCLUSIONS

Arthroscopic Bankart repair enabled good clinical outcomes and complete quantitative labrum restoration parameters. Next to several well-known parameters, secondary osteoarthritis after arthroscopic Bankart repair significantly correlated with osteoarthritic status of the uninjured contralateral shoulder but was not influenced by quantitative labrum restoration. The recommendation for arthroscopic Bankart repair should be based on clinical parameters and not on prevention of secondary osteoarthritis.

STUDY DESIGN

Case series.

LEVEL OF EVIDENCE

IV.

Revisiting the Anterior Glenoid: An Analysis of the Calcified Cartilage Layer, Capsulolabral Complex, and Glenoid Bone Density

PURPOSE

In this cadaveric study, we aim to define the basic anatomy of the anterior glenoid with attention to the relationships of calcified cartilage, capsulolabral complex, and osseous morphology of the anterior glenoid.

METHODS

Seventeen cadaveric glenoid specimens (14 male, 3 female, mean age 53.9 ± 10) were imaged with micro-computed tomography (CT) and embedded in poly-methyl-methacrylate. Specimens were included for final analysis only if the entire glenoid articular cartilage, labrum, capsule, and biceps insertion were pristine and without evidence of injury, degeneration, or damage during the preparation process. Group 1 members (n = 9) were axially sectioned through 3 to 9 o'clock and 4 to 8 o'clock; group 2 members (n = 8) were radially sectioned through 3, 4, 5, and 9 o'clock. A scanning electron microscope (SEM) analysis quantified the percentage of bone within a 5 × 2.5 mm region at the glenoid rim. Micro-CT, SEM, and light microscopy evaluated the capsulolabral complex and calcified fibrocartilage.

RESULTS

A 7 ± 2.1 mm region of calcified fibrocartilage at 4 o'clock was identified from the articular face to the medial glenoid neck supporting the overlying capsulolabral footprint and was >3× thicker at the articular attachment (316 ± 153 μm) versus the glenoid neck (92 ± 66 μm). At 3 to 9 o'clock and 4 to 8 o'clock 79.2% ± 5.4% and 75.2% ± 7.8% of the glenoid osseous width was covered with articular cartilage. The labrum accounted for 13.1% ± 3.4% of the glenoid width at 4 o'clock. SEM analysis demonstrated decreased glenoid bone density at 3, 4, and 5 o'clock (P ≤ .015) and no difference (P = .448) at 9 o'clock versus central subchondral bone.

CONCLUSIONS

The capsulolabral footprint contributes significantly to the glenoid face, inserts directly adjacent to the articular cartilage, and extends medially along the glenoid neck. A layer of calcified fibrocartilage lies immediately beneath the capsulolabral footprint and is 3× thicker at the articular insertion compared with the glenoid neck. Lastly, there is a bone density gradient at the anterior-inferior rim versus the central subchondral bone.

CLINICAL RELEVANCE

Arthroscopic Bankart repair has been reported to have a significant failure rate in many settings. It is felt that reproducing anatomy with the repair could help improve outcomes. Based on this study's findings, an arthroscopic Bankart technique that most closely reproduces native anatomy and potentially optimizes soft-tissue healing could be performed. This includes removal of 1 to 2 mm of articular cartilage from the glenoid face with anchor placement at this location to appropriately reposition the capsulolabral complex.

What Are the Effects of Capsular Plication on Translational Laxity of the Glenohumeral Joint: A Study in Cadaveric Shoulders

BACKGROUND

Surgical treatment for shoulder instability generally involves labral repair with a capsular plication or imbrication. Good results are reported in both open and arthroscopic procedures, but there is no consensus on the amount or location of capsular plication that is needed to achieve stability and anatomic anterior, posterior, and inferior translation of the joint.

QUESTIONS/PURPOSES

(1) What are the separate and combined effects of increasing plication magnitude and sequential additive plications in the anterior, posterior, and inferior locations of the joint capsule on glenohumeral joint translation in the anterior, posterior, and inferior directions? (2) What plication location and magnitude restores anterior, posterior, and inferior translation to a baseline level?

METHODS

Fourteen cadaveric shoulders were dissected down to the glenohumeral capsule and underwent instrumented biomechanical testing. Each shoulder was loaded with 22 N in anterior, posterior, and inferior directions at 60° abduction and neutral rotation and flexion and the resulting translation were recorded. Testing was done over baseline (native), stretched (mechanically stretched capsule to imitate a lax capsule), and 5-mm, 10-mm, and 15-mm plication conditions. Individually, for each of the 5-, 10-, and 15-mm increments, plications were done in a fixed sequential order starting with anterior plication at the 3 o'clock position (Sequence I), then adding posterior plication at the 9 o'clock position (Sequence II), and then adding inferior plication at the 6 o'clock position (Sequence III). Each individual sequence was tested by placing 44 N (10 pounds) of manual force on the humerus directed in an anterior, posterior, and inferior direction to simulate clinical load and shift testing. The effect of plication magnitude and sequence on translation was tested with generalized estimating equation models. Translational differences between conditions were tested with paired t-tests.

RESULTS

Translational laxity was highest with creation of the lax condition, as expected. Increasing plication magnitude had a significant effect on all three directions of translation. Plication location sequence had a significant effect on anterior and posterior translation. An interaction effect between plication magnitude and sequence was significant in anterior and posterior translation. Laxity in all directions was most restricted with 15-mm plication in anterior, posterior, and inferior locations. For anterior translational laxity, at 10-mm and 15-mm plication, there was a progressive decrease in translation magnitude (10-mm plication anterior only: 0.46 mm, plus posterior: 0.29 mm, plus inferior, -0.12 mm; and for 15-mm anterior only: -0.53 mm, plus posterior: -1.00 mm, plus inferior: -1.66 mm). For posterior translational laxity, 10-mm and 15-mm plication also showed progressive decrease in magnitude (10-mm plication anterior only: 0.46 mm, plus posterior: -0.25 mm, plus inferior: -1.94; and for 15-mm anterior only: 0.14 mm, plus posterior: -1.54 mm, plus inferior: -3.66). For inferior translational laxity, tightening was observed only with magnitude of plication (anterior only at 5 mm: 0.31 mm, at 10 mm: -1.39, at 15 mm: -3.61) but not with additional plication points (adding posterior and inferior sequences). To restore laxity closest to baseline, 10-mm AP/inferior plication best restored anterior translation, 15-mm anterior plication best restored posterior translation, and 5 mm posterior with or without inferior plication best restored inferior translation.

CONCLUSIONS

Our results suggest that (1) a 10-mm plication in the anterior and posterior or anterior, posterior, and inferior positions may restore anterior translation closest to baseline; (2) 10-mm anterior and posterior or 15-mm anterior plications may restore posterior translation closest to baseline; and (3) 5-mm anterior and posterior or anterior, posterior, and inferior plications may restore inferior translation closest to baseline. Future studies using arthroscopic techniques for plication or open techniques via a true surgical approach might further characterize the effect of plication on glenohumeral translation.

CLINICAL RELEVANCE

This study found that specific combinations of plication magnitude and location can be used to restore glenohumeral translation from a lax capsular state to a native state. This information can be used to guide surgical technique based on an individual patient's degree and direction of capsular laxity. In vivo testing of glenohumeral translation before and after capsular plication will be needed to validate these cadaveric results.

The cost-effectiveness of the arthroscopic Bankart versus open Latarjet in the treatment of primary shoulder instability

BACKGROUND

The purpose of this study was to conduct a cost-effectiveness analysis of the arthroscopic Bankart and the open Latarjet in the treatment of primary shoulder instability.

METHODS

This cost-effectiveness study used a Markov decision chain and Monte-Carlo simulation. Existing literature was reviewed to determine the survivorship and complication rates of these procedures. Health utility states (EQ-5D and quality-adjusted life-years) of the Bankart and Latarjet were prospectively collected. Using these variables, the Monte-Carlo simulation was modeled 100,000 times.

RESULTS

In reviewing the literature, the overall recurrence rate is 14% after the arthroscopic Bankart and 8% after the open Latarjet. Postoperative health utility states were equal between the 2 procedures (mean EQ-5D, 0.930; P = .775). The Monte-Carlo simulation showed that the Bankart had an incremental cost-effectiveness ratio of $4214 and the Latarjet had an incremental cost-effectiveness ratio of $4681 (P < .001).

CONCLUSION

Both the arthroscopic Bankart and open Latarjet are highly cost-effective; however, the Bankart is more cost-effective than the Latarjet, primarily because of a lower health utility state after a failed Latarjet. Ultimately, the clinical scenario may favor Latarjet (ie, critical glenoid bone loss) in certain circumstances, and decisions should be made on a case by case basis.

Long-term results of arthroscopic Bankart repair: Minimum 10 years of follow-up

PURPOSE

This study investigated the long-term results of arthroscopic Bankart repair in terms of rates and timelines of recurrence of instability, with special interest in young adult patients aged ≤20 years.

METHODS

Between 2000 and 2005, 186 shoulders [182 patients, 50 women, median age 26 (range 15-58) years] were operated on at a university hospital using arthroscopic Bankart repair because of instability after traumatic anteroinferior shoulder dislocation. Medical records were retrospectively reviewed and patients were assessed using postal questionnaires or telephone interview after a minimum of 10 years of follow-up [median 12.2 (range 10-16) years]. The primary outcome measure was recurrence of instability (assessed from 167 shoulders), other outcome measures included Oxford instability score (OIS), subjective shoulder value (SSV), and Western Ontario instability index (WOSI) (assessed from 157 shoulders).

RESULTS

At the end of follow-up, 50/167 shoulders (30%) had recurrence of instability and 30/167 (18%) were subjected to reoperation due to instability symptoms. Twenty-six (52%) failures occurred within ≤2 years, 11 (22%) within 2-5 years, and 13 (26%) >5 years after surgery. Failure rate was 19/35 (54%) for patients aged ≤20 years and 31/132 (24%) for patients aged >20 years; reoperation rates were 11/35 (31%) and 19/132 (14%), respectively. Mean OIS was 20 (SD 9, range 12-50), SSV 83% (SD 21, range 10-100), and WOSI score 80 (SD 22, range 33-100).

CONCLUSIONS

Nearly one-third of patients had recurrence of instability after arthroscopic Bankart repair after a minimum of 10-year follow-up. Patients aged ≤20 years did poorly with more than half of the patients having recurrence; alternative stabilization techniques should probably be considered for these patients.

LEVEL OF EVIDENCE

IV.

Contraindications and complications of the Latarjet procedure

The Latarjet procedure is a well-known, safe and reliable technique to treat primary or recurrent anterior dislocations or subluxations, with or without hyperlaxity, with or without glenoid bone loss. Both the open and the arthroscopic methods produce excellent clinical results, with a low rate of recurrent instability. There have been concerns of a higher surgical complication rate associated with this procedure, however, large reviews reported an overall complication rate in the open Latarjet procedure of 15%. Meticulous surgical technique and a good understanding of the local anatomy can help to avoid the complications but postoperative shoulder arthritis and frequent bone block osteolysis remain unsolved additional challenges, which require further research. There are 2 main factors to further improve the clinical outcome and patient satisfaction: careful patient selection with good surgical indication, and reducing complications with adequate surgical techniques. The aim of this study is to provide the current overview of the contraindications and complications of the Latarjet procedure.

Analysis of postoperative monitoring of patients undergoing shoulder arthroscopy for anterior instability

OBJECTIVE

Analyze the postoperative follow-up of patients undergoing shoulder arthroscopy for treatment of anterior instability and correlate with the prevalence of recurrence.

METHODS

A six-question survey was applied by phone and mail to 65 patients, seeking information on the current result of the surgical procedure. All patients were treated arthroscopically for anterior shoulder instability, with at least 12 months of postoperative time. Patients with associated posterior labial lesions and revision surgeries were not included.

RESULTS

At the time of the survey the patients had a median of 56 (IQR: 34.5-110.5) postoperative months. The mean sample age was 24.6 years (maximum = 47, minimum = 12; SD = 7.3). Complaint of pain in the shoulder was observed in 20 patients (30.7%). Dislocation recurrence was observed in 10 patients (15.3%). Forty-four patients (67.6%) considered their shoulder normal, which was more frequent in non-recurrence patients (p < 0.001). Forty-three patients (66.1%) returned to their previous level of sport and there was no difference between recurrence and non-recurrence patients (p = 0.456). It was found that the prevalence of recurrence was 5.6 (95% CI: 1.30-24.46) times higher in individuals who abandoned monitoring before six months postoperatively (p = 0.012).

CONCLUSION

The abandonment of postoperative monitoring in the early stages, when the patients receive orientation for muscle strengthening, proprioceptive education, and dangerous movements to avoid, can increase the rates of recurrent shoulder dislocation in patients treated for anterior instability by arthroscopy.

Results of Arthroscopic Bankart Repair for Anterior-Inferior Shoulder Instability at 13-Year Follow-up

BACKGROUND

Anterior-inferior shoulder instability is a common injury in young patients, particularly those practicing overhead-throwing sports. Long-term results after open procedures are well studied and evaluated. However, the long-term results after arthroscopic repair and risk factors of recurrence require further assessment.

HYPOTHESIS

Arthroscopic Bankart repair results are comparable with those of open repair as described in the literature.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 180 shoulders with anterior-inferior shoulder instability were stabilized arthroscopically, met the inclusion criteria and the patients were able to be contacted at a minimum of 10-year follow-up. Of these patients, 143 agreed to participate in the study. Assessment was performed clinically in 104 patients using the American Shoulder and Elbow Surgeons score, Constant score, American Academy of Orthopaedic Surgeons score, Rowe score, and the Dawson 12-item questionnaire. The Samilson-Prieto score was used to assess degenerative arthropathy in radiographs available for 100 shoulders. Additionally, 15 patients participated through a specific questionnaire and 24 patients through a telephone survey.

RESULTS

The overall redislocation rate was 18.18%. Redislocation rates for the different types of fixation devices were as follows: FASTak/Bio-FASTak, 15.1% (17/112); SureTac, 26.3% (5/19); and Panalok, 33.3% (4/12). Concomitant superior labral anterior-posterior repair had no effect on clinical outcome. Redislocation rate was significantly affected by the patient's age and duration of postoperative rehabilitation. Redislocation rate tended to be higher if there had been more than 1 dislocation preoperatively ( P = .098). Severe dislocation arthropathy was observed in 12% of patients, and degenerative changes were significantly correlated with the number of preoperative dislocations, patient age, and number of anchors. The patient satisfaction rate was 92.3%, and return to the preinjury sport level was possible in 49.5%.

CONCLUSION

Clinical outcome at a mean follow-up of 13 years after arthroscopic repair of anterior-inferior shoulder instability is comparable with the reported results of open Bankart repair in the literature and allows management of concomitant lesions arthroscopically. Modifiable risk factors of postoperative redislocation and arthropathy must be considered. Stabilization after the first-time dislocation achieves better clinical and radiological outcomes than after multiple dislocations.

Mid-term results of arthroscopic Bankart repair: A review of 31 cases

INTRODUCTION

The goal of this study was to assess the overall function (Walch-Duplay score), stability, time and because it is time of return to sport and level of return to sport, and satisfaction of patients who underwent an arthroscopic Bankart repair for chronic anterior shoulder instability at 5 years' follow-up. In addition, the potential correlation between the postoperative Walch-Duplay score and the presence of risk factors for recurrence, the ISIS score, associated labral lesions discovered intraoperatively and clinical presentation was determined.

MATERIAL AND METHODS

This was a retrospective, single-centre study of 30 patients (31 arthroscopic Bankart procedures) operated between January 2003 and December 2012. The Walch-Duplay score, recurrence rate (dislocation or subluxation), return to sports and subjective satisfaction were evaluated.

RESULTS

The mean postoperative Duplay score was 77.4 points (100-15)±30.6. At review, 25.8% of patients had recurrence of the preoperative symptoms, including 16.1% glenohumeral dislocation and 9.7% subluxation. Patients requiring revision surgery (Bristow-Latarjet procedure) had no additional instability episodes. Among the athletes, 16 (66.6%) returned to their pre-injury level, four (16.6%) changed to a different sport and four stopped participating (16.6%). The subjective evaluation of the procedure was satisfactory in 75% of cases. No risk factors for recurrence were significantly related to the Walch-Duplay score.

CONCLUSION

Despite satisfactory Walch-Duplay scores and subjective results, this mid-term follow-up study revealed a significant number of patients with recurrent instability after arthroscopic Bankart repair, confirming published data. Careful patient selection is essential prior to proposing this procedure and patients should be informed of the potential risk of revision surgery.

LEVEL OF EVIDENCE

Level IV, retrospective study.

Arthroscopic Bankart shoulder stabilization in athletes: return to sports and functional outcomes

PURPOSE

The aim of this study was to evaluate return to sports after arthroscopic Bankart stabilization.

METHODS

This is a retrospective study including all athletes aged <50 years who underwent arthroscopic stabilization in 2010 and 2011 (m, 36; f, 10; mean age 28.9 ± 8.1 years; follow-up 24.4 ± 7.7 months). Sixteen patients were practicing competitive sports and 30 recreational sports. Level and delay of return to sports, sports classification according to Allain, Western Ontario Shoulder Instability Index (WOSI) score, patient satisfaction, apprehension level and avoidance behaviour were noted.

RESULTS

95.7 % returned to the same level after an average of 9.8 ± 5.4 months. Sports level was unchanged or better in 82.6 %, lower in 8.7, and 4.5 % changed sport because of their shoulder. Patients with more than 10 dislocations returned to sports and to their preoperative level later than patients with <10. Male athletes returned to preoperative sports levels faster than female athletes (p < 0.001). The WOSI score and also its item "sports" were worse in those who had not returned (p = 0.0002 and 0.006, respectively). Satisfaction correlated with the WOSI score (p = 0.0004) while 93.3 % were satisfied/very satisfied. The decrease in the apprehension level was significant (p < 0.00001). 36.9 % still experienced avoidance behaviour.

CONCLUSIONS

Most athletes resumed their main sport often at the same level, but the threshold of 10 dislocations should be considered a risk factor for longer return to sports at any level. The WOSI score is a valuable outcome score after Bankart stabilization. Postoperative avoidance should be distinguished from apprehension.

LEVEL OF EVIDENCE

IV.

Arthroscopic Implant-Free Bone Grafting for Shoulder Instability With Glenoid Bone Loss: Clinical and Radiological Outcome at a Minimum 2-Year Follow-up

BACKGROUND

Posttraumatic anteroinferior shoulder dislocations with concomitant glenoid bone loss show high recurrence rates. The open J-bone graft technique for implant-less anatomic restoration of bony glenoid structure has previously been described, whereas results of arthroscopic techniques are currently not available.

PURPOSE

To evaluate clinical and radiological outcome after arthroscopic anatomic reconstruction of the glenoid for recurrent anteroinferior glenohumeral instability.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Fifteen shoulders of 14 patients with recurrent anteroinferior shoulder instability were prospectively followed after glenoid reconstruction with a modified arthroscopic, implant-free J-bone graft. Preoperatively, the instability severity index score was documented. Patients were followed for a minimum of 2 years using the Rowe score and the Constant score. Subjective outcome was assessed using a visual analog scale (VAS) for pain and the subjective shoulder value for sports (SSVS); satisfaction with procedure outcome was also rated. Range of motion was recorded. Incidence of recurrent instability, defined as dislocation, subluxation, or persistent apprehensiveness, was documented. Pre- and postoperative (1 day and 3, 12, and 24 months) computed tomographic images were used to evaluate glenoid bone loss, reconstruction of the glenoid, and graft remodeling.

RESULTS

All preoperative scores (Rowe score: 57.6 ± 14.4; Constant score: 70.9 ± 8.9; VAS: 4.4 ± 2.6; SSVS: 31.4% ± 19.5%) were significantly (P ≤ .02) improved at final follow-up (Rowe score: 98.6 ± 1.5; Constant score: 96.3 ± 3.9; VAS: 0.2 ± 0.6; SSVS: 95.6% ± 3.8%). The preoperative glenoid area (82.1% ± 4.5%) was significantly increased immediately after surgery to 99.2% ± 6.6% (P < .001). After a physiological remodeling process, the glenoid area remained significantly increased at the latest follow-up (89.5 ± 3.2%, P < .001). J-bone grafting successfully restored glenoid concavity by significantly increasing concavity extent and depth from preoperative (19.8 ± 2.1 and 0.9 ± 0.6 mm, respectively) to postoperative (24.0 ± 2.1 and 2.1 ± 0.8 mm, respectively) (P < .001). There were no recurrent instabilities. One traumatic graft fracture occurred during the follow-up period.

CONCLUSION

The arthroscopic J-bone graft technique permits minimally invasive reconstruction of anteroinferior glenoid defects and provided excellent early clinical outcome without recurrent instability in posttraumatic shoulder dislocations. A physiological remodeling process leads to restoration of a more natural glenoid anatomy.

Bankart repair versus Bankart repair plus remplissage: an in vitro biomechanical comparative study

PURPOSE

To biomechanically compare Bankart lesion repair alone and Bankart lesion repair associated with infraspinatus capsulotenodesis described as «remplissage», in the treatment of combined Bankart and Hill-Sachs lesions.

METHODS

Seven pairs (right and left) of cadaveric shoulders have been tested, first without any lesion and then after performing a combined Bankart and Hill-Sachs lesions. For each pair, the specimens were then randomly assigned for Bankart lesion repair alone on one side or for Bankart lesion repair associated with remplissage on the other side. During tests, the shoulder was placed at 90° of abduction and at maximal external rotation, which value was recorded. A 50 N postero-anterior load was then applied to the proximal humerus, and the stiffness was calculated from the obtained load-displacement curve.

RESULTS

Bankart and Hill-Sachs lesions significantly (p < 0.05) decreased joint stiffness compared with intact joint. Bankart lesion repair alone did not restore stiffness to the level of intact, while adding the remplissage to the Bankart lesion repair did. External rotation was significantly increased after creation of the Bankart and Hill-Sachs lesion; Bankart repair restored the external rotation to the level of intact, while Bankart lesion repair associated with remplissage significantly decreased external rotation compared with intact and to Bankart lesion repair alone.

CONCLUSION

In cadaveric shoulders with combined Bankart and Hill-Sachs lesions, Bankart lesion repair associated with remplissage restored intact joint stiffness contrary to Bankart lesion repair alone. This increase in stiffness was associated with a decrease in external rotation.

Predictors of functional outcomes and recurrent shoulder instability after arthroscopic anterior stabilization

PURPOSE

To investigate what factors might predict the results of arthroscopic stabilization for anterior shoulder instability.

METHODS

One hundred and forty-three patients averaging 25 (15-58) years with traumatic anterior shoulder instability who underwent arthroscopic stabilization were reviewed at a median follow-up of 81 (24-172) months. Sixty-two (56.4 %) individuals were involved in contact sport activities, and there were 40 (30 %) patients who had only one dislocation prior to having surgery. Rowe score was measured preoperatively and at follow-up.

RESULTS

Thirty-three (23.1 %) patients experienced recurrent instability 12 (1-120) months after surgery, and 15 of those underwent further surgery. There was a statistically significant lower risk of failure (p = 0.027) for patients who had a surgical procedure after only one episode of shoulder dislocation. Patients treated after the second or further episode of shoulder dislocation exhibited a mean odds ratio for failure of 3.8 (95 % confidence interval 1.2-11.6, p = 0.044) with regard to first-time dislocators. The Rowe score significantly improved from a preoperative value of 25 (5-55) to a postoperative value of 100 (40-100) (p < 0.001). A significantly higher postoperative Rowe score was found in patients older than 24 years of age at the operation (p = 0.011) and in patients with less than eight dislocations prior to surgery (p = 0.05).

CONCLUSIONS

These results suggest that better functional results following arthroscopic stabilization can be expected in patients over 24 years of age and in those with a fewer number of dislocations preoperatively. A lower rate of recurrence can be expected if the patient undergoes surgery after the first episode of dislocation.

LEVEL OF EVIDENCE

Prognostic study, Level II.

Arthroscopic Repair of a Posterior Bony Bankart Lesion

Posterior bony defects of the glenoid rim, particularly those associated with instability, are often a frustrating challenge for arthroscopists because of the defects' inaccessibility from standard portals. This challenge is enhanced when the lesion is chronic and fibrous malunion of the fragment makes mobilization difficult. We present our technique for arthroscopic repair of the relatively uncommon chronic posterior bony Bankart lesion. By use of lateral positioning and a standard anterior viewing portal and posterior working portal, as well as a strategically placed posterolateral accessory portal, the lesion is first freed from its malreduced position and ultimately repaired using suture anchor fixation of the bony fragment along with its associated labrum directly to the remaining glenoid rim. This technique, facilitated by precise portal placement, results in satisfactory fragment reduction, appropriate capsular tension, and restoration of anatomy.

Open Bankart Repair for the Treatment of Anterior Shoulder Instability without Substantial Osseous Glenoid Defects: Results After a Minimum Follow-up of Twenty Years

BACKGROUND

Neglected osseous glenoid defects are thought to be one of the reasons for the reported high rates of recurrent instability at long-term follow-up after Bankart repair. We hypothesized that open Bankart repair for the treatment of anterior glenohumeral instability in the absence of a substantial osseous glenoid defect would result in a lower long-term recurrence rate than has been reported in previous long-term studies.

METHODS

Forty-seven patients were treated with a primary modified open Bankart repair for recurrent anterior shoulder instability between 1989 and 1994. Double-contrast computed tomography scanning was used to exclude patients with a substantial osseous glenoid defect. Forty patients (85.1%) were available for subjective and objective follow-up at a minimum of twenty years (maximum, twenty-five years). Twenty-six patients (65%) underwent clinical examination as well as bilateral shoulder radiography, and fourteen (35%) completed a self-assessment questionnaire and were interviewed by telephone.

RESULTS

Seven patients (17.5%) had a recurrence of instability, and six of them had the instability occur after more than eight years without symptoms. The mean Western Ontario Shoulder Instability Index score (and standard deviation) was 256.7 ± 284.8 points; the mean Rowe score, 88.7 ± 12.0 points; and the mean Subjective Shoulder Value, 90.1% ± 10.5%.The mean range of motion of the affected shoulder was decreased by 4° of abduction (p = 0.009), two levels of internal rotation (p = 0.003), 5° of internal rotation in 90° of abduction (p = 0.005), 7° of external rotation in neutral position (p < 0.001), and 7° of external rotation in 90° of abduction (p = 0.004) compared with the contralateral side. The collective instability arthropathy (CIA) index was 0.92 for the affected side and 0.35 for the contralateral side.

CONCLUSIONS

Open Bankart repair provides good results twenty years after surgery in terms of subjective and objective outcome measurements. However, the long-term failure rate remains high despite the exclusion of substantial osseous glenoid defects. Recurrence of instability seems to be associated with an increased shoulder-specific activity level.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcome of Bankart repair in contact versus non-contact athletes

BACKGROUND

The clinical results of arthroscopic Bankart repair for contact athletes varies according to published reports. The purposes of this study were to analyze the clinical outcome of open or arthroscopic Bankart repair and to investigate the results in contact and non-contact athletes.

HYPOTHESIS

Clinical outcome of arthroscopic Bankart repair is similar to that of open procedure.

PATIENTS AND METHODS

One hundred patients with recurrent anterior shoulder dislocation without a large bony defect were retrospectively reviewed. Fifty-one contact and 49 non-contact athletes were found with a mean follow-up of 17 months. Forty-nine shoulders underwent arthroscopic Bankart repairs; 51 shoulders had open Bankart repairs.

RESULTS

In non-contact athletes, there was a 5% (1/22 cases) recurrence rate in the open group and 4% (1/27 cases) in the arthroscopic group. In contrast, in contact athletes, there was a 10% (3/29 cases) recurrence rate in the open group and 14% (3/22 cases) in the arthroscopic group. There was no significant difference in the recurrence rate between contact and non-contact athletes, although contact athletes showed two to three times a higher recurrence rate than that of non-contact athletes. The Rowe score and Constant score showed no significant difference between the two procedures and between the contact and non-contact athletes. The rate of the complete return to sports showed no significant difference between contact and non-contact athletes.

CONCLUSION

The recurrence rate of Bankart repair in the contact athletes was 2 times higher in the open group and 3 times higher in the arthroscopic group than in the non-contact athletes. Clinical outcome of arthroscopic Bankart repair was similar to that of open procedure.

Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Long-term Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13-Year Follow-up

BACKGROUND

Glenohumeral osteoarthritis is a well-documented, long-term complication of open stabilization procedures. However, there is a lack of knowledge about long-term radiographic outcome after arthroscopic Bankart procedures.

HYPOTHESIS

Glenohumeral osteoarthritis will develop less frequently in arthroscopic Bankart repair compared with open repairs reported in the literature.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The inclusion criteria for this study were (1) all-arthroscopic Bankart repair for a (2) symptomatic anteroinferior shoulder instability and (3) a minimum follow-up of 10 years. True anteroposterior and lateral radiographs were obtained to evaluate the prevalence and grade of osteoarthritis according to the Samilson classification. Patients were assessed by the Constant score and examined for passive external rotation deficits.

RESULTS

Of 165 shoulders that fulfilled the inclusion criteria, 100 were available for evaluation. The median Constant score at an average±SD 156.2±18.5 months after Bankart repair was 94 (range, 46-100). Twenty-one shoulders (21%) sustained a recurrent dislocation. Overall, 31% of shoulders showed no evidence of glenohumeral osteoarthritis; 41% showed mild, 16% moderate, and 12% severe degenerative changes. Osteoarthritis did not correlate with Constant score results (P=.427). The grade of osteoarthritis was significantly associated with the number of preoperative dislocations (P=.016), age at initial dislocation (P=.005) and at surgery (P=.002), and the number of anchors used (P=.001), whereas time from initial dislocation to surgery (P=.854) and external rotation deficit at 0° and 90° of abduction (P=.104 and .348, respectively) showed no significant correlation. Recurrent dislocation did not affect the presence or grade of osteoarthritis (P=.796 and .665, respectively).

CONCLUSION

At an average 13 years after arthroscopic Bankart repair, osteoarthritic changes are a common finding and, overall, are comparable with reports in the literature regarding open procedures as well as nonoperative treatment. The extent of trauma sustained during preoperative dislocations and the age of the patient seem to be more relevant for long-term dislocation arthropathy than the kind of treatment. Accordingly, the study hypothesis must be rejected. Avoiding preoperative dislocations is more important for the prevention of osteoarthritis than short-term treatment. The number of anchors used was found to be a predictor for long-term development of osteoarthritis.