Arthroscopic Bankart suture repair

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Variations in common operations in athletes and non-Athletes

Background

Achieving pre-injury activity level after an injury is the fundamental goal of any orthopedic treatment for an athlete. Unfortunately, pre-injury activity levels differ significantly in different patient categories, especially in athletes and non-athlete. Hence, an outcome suitable to a non-athlete may not be adequate for an athlete. This has led to variations in the surgical approach to the same injury in an athlete and non-athlete.There is plenty of literature published comparing the outcome in athletes and non-athletes after a particular surgery. Scattered discussion about variations in these surgeries based on functional demand was done in many publications. But there was a lack of a comprehensive narrative review summarizing variations in common operations among athletes and non-athletes.

Aim

This review attempted to summarize variations in common sports operations between high functional demand patients and low demand patients and discuss the variations from the author's perspective.

Methods

A review of all the relevant papers were conducted focusing on athletes and non-athletes. Most commonly performed sports surgeries were ACL reconstruction, Meniscal repair, PCL reconstruction, and Shoulder instability surgery. A literature search was done for each commonly performed surgery using relevant keywords in PubMed and Google Scholars. Summary of papers pertinent to athletes and non-athletes were compiled to prepare this narrative review.

Results

There is a lack of papers directly comparing results in athletes and non-athletes. However, many research papers discussed surgical variations in athletes (high demand) and non-athletes (low demand) patients. There are controversies in all commonly performed surgeries, and none of the papers gives a definitive guideline on the approach to athletes and non-athlete.

Conclusion

Rather than a common suggestion on surgical variation, an individualized approach would be appropriate to decide on variation in particular surgery in both athletes and non-athletes.

Can We Identify Why Athletes Fail to Return to Sports After Arthroscopic Bankart Repair: A Systematic Review and Meta-analysis

BACKGROUND

No previous systematic reviews have reported on athletes who fail to return to sports after arthroscopic Bankart repair.

PURPOSE

To review the literature on athletes who fail to return to sports after arthroscopic Bankart repair to determine the rate of athletes who did not return to sports and to identify the specific reasons for failure to return to sports by nonreturning athletes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A meta-analysis was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Three electronic databases (PubMed, Scopus, Web of Science) were queried for articles meeting the inclusion criteria. Studies were considered eligible only if reporting the rate of failure for return to sports and providing the specific reasons why athletes were unable to return to sports. All records were screened by title, abstract, and full text by 2 authors independently, with any discrepancies resolved by a third senior author. For articles selected for inclusion, data were collected on the number of athletes, average age, average follow-up time, type of sport played, rate of failure to return to sports, and specific reasons for failure to return. A random-effects model was used to conduct the meta-analysis.

RESULTS

Seventeen studies were selected for inclusion reporting on a total of 813 athletes. The calculated weighted rate of failure to return to sports after arthroscopic Bankart repair was 15.6% (95% CI, 10.9%-21.1%). A significantly higher proportion of athletes cited shoulder-dependent versus shoulder-independent reasons for failure to return to sports (81.7% vs 18.3%; P < .0001). The most cited reasons for failure to return included recurrent or persistent instability (33.3%), fear of reinjury (17.7%), apprehension (9.9%), changes in priorities or personal interest (8.5%), lack of time (7.1%), and discomfort or pain with sports (6.4%).

CONCLUSION

Our study estimated the rate of failure to return to sports after arthroscopic Bankart repair to be 15.6%, with most athletes citing shoulder-related reasons as the primary factor precluding return. Identifying the potential reasons preventing successful return to sports can guide surgeons in counseling athletes regarding postoperative expectations and addressing hesitations for returning to sports.

Mid- to long-term results of postoperative immobilization in internal vs. external rotation after arthroscopic anterior shoulder stabilization

Background

There is still a disagreement on the postoperative rehabilitation concerning position of immobilization of the shoulder after arthroscopic anterior shoulder stabilization and its influence on the clinical outcome. The aim of this study was to evaluate the clinical results and the recurrence rate after arthroscopic anteroinferior shoulder stabilization and postoperative immobilization in internal rotation vs. external rotation.

Methods

Twenty-five patients (22 male and 3 female, mean age 28.5 years) were included in this prospective nonrandomized cohort study. In group I (11 male, 2 female, mean age 28 years), the postoperative functional immobilization was carried out in internal rotation of 60°, and in group II (11 male, 1 female, mean age 30 years), 15° of external rotation of the arm for 4 weeks in both groups. The clinical follow-up was performed at 2, 4, and 6 weeks as well as at 3, 6, and 12 months postoperatively including assessment of range of motion and functional shoulder scores (Subjective Shoulder Value, Constant score, Rowe score, Walch Duplay score, Melbourne Instability Shoulder Score). Furthermore, shoulder instability was evaluated using the apprehension, relocation, and surprise tests. Mid-term follow-up data were additionally assessed after a minimum of 4 years.

Results

Twenty patients (19 male and 1 female) with an average age of 28 years were followed up for 62 (53-72) months after arthroscopic stabilization. The comparison of both groups showed almost equal results regarding the range of motion without any significant differences (P > .05). The evaluation of the shoulder function scores also showed no significant differences with an average Subjective Shoulder Value of 95% vs. 91%, Constant score of 89 vs. 88 points, Rowe score of 96 vs. 94 points, Walch Duplay score of 86 vs. 89 points, Melbourne Instability Shoulder Score of 96 points, and Western Ontario Shoulder Instability Index of 88% vs. 84% (P > .05). There was no recurrent dislocation in both groups.

Conclusion

The type of immobilization after arthroscopic shoulder stabilization does not influence the clinical results after a mid- to long-term follow-up.

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.

The 50 Most-Cited Papers on Bankart Lesions

Purpose

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

Methods

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

Results

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

Conclusions

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

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.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Controlled laboratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Mechanism and patterns of bone loss in patients with anterior shoulder dislocation

BACKGROUND

Bony defects are common injuries associated with anterior shoulder dislocation. It is generally thought that these bony defects are created at the time of dislocation. However, there have been no biomechanical reports demonstrating the exact time point when these lesions occur. The purpose of this study was to clarify when, how, and which types of bony defects were created during experimental dislocation in cadaveric shoulders.

METHODS

Fifteen fresh-frozen cadaveric shoulders (mean age at the time of death, 79 years) were fixed in a custom testing machine. First, the glenohumeral joint was inspected by arthroscopy. Then, the arm was held at 60° of abduction and maximum external rotation and was manually extended horizontally under fluoroscopy until an anterior dislocation occurred. Next, a force of 800 N was applied to a Kirschner wire inserted in the humeral head in the direction of the pectoralis major with use of an air cylinder. We waited until the arm came to equilibrium under this condition. Finally, the glenohumeral joint was arthroscopically examined. We further performed x-ray micro-computed tomography and histologic examination in 1 shoulder with a bipolar lesion.

RESULTS

After the anterior dislocation, a Bankart lesion was created in 9 of 15 shoulders and a fragment-type glenoid defect (avulsion fracture) was created in 4. A Hill-Sachs lesion, on the other hand, was not observed after the dislocation. The equilibrium arm position was 40° ± 17° in flexion, 45° ± 22° in abduction, and 27° ± 19° in external rotation. In this arm position, newly created lesions were Hill-Sachs lesions in 6 shoulders and erosion-type glenoid defects (compression fracture) in 7. Micro-computed tomography, performed in a single specimen, showed a flattened anterior glenoid rim with collapse of trabecular bone. Histologic analysis of nondecalcified sections using hematoxylin-eosin staining indicated that the anterior rim of the glenoid was compressed and flattened. The cortex of the anterior glenoid rim could be clearly observed.

CONCLUSION

The fragment-type glenoid defect (avulsion fracture) was observed at the time of dislocation, whereas the erosion-type defect (compression fracture) was observed when the arm came to equilibrium in the midrange of motion. Hill-Sachs lesions were created not at the time of dislocation but after the arm came to equilibrium.

LATARJET PROCEDURE ON ANTERIOR SHOULDER INSTABILITY IN PROFESSIONAL SOCCER PLAYERS

Anterior glenohumeral instability is a frequent cause of professional soccer players’ removal, reduced performance, and prolonged recovery. Players are subjected to intense physical contact and high performance, thus demanding lower rates of recurrence after surgical correction so they can return to sport quickly.

Traumatic Anterior Instability: Treatment Options for Initial Instability

Because of the lack of bony restraints and minimal articular contact, the glenohumeral joint can attain significant range of motion; however, this results in the propensity for instability. The most generic form of instability, traumatic anterior instability, reliably produces a series of pathoanatomic findings. While reliable, these findings contribute to the complexities of caring for patients after an initial instability event. Numerous studies have examined this issue and determined that careful consideration of patient factors can guide successful treatment, whether it be surgical or nonsurgical, after initial instability. Such forms of treatment have shown to provide a good functional outcome and decreases morbidity. To be able to provide successful treatment requires a thorough understanding of the pathoanatomic of an instability event and the intricacies of the evaluation of a patient after an initial instability event.

Fixation methods and implants in shoulder stabilization: A historical perspective

BACKGROUND

Treatment for shoulder instability has changed significantly over the past decade from open procedures to arthroscopic procedures using a variety of different fixation methods and implants. The development of these implants has been highly influenced by the numerous complications that have arisen using early designs.

METHODS

A review of the literature was performed to describe the history of shoulder stabilization.

CONCLUSION

As biomedical technology improves, we should continue to see changes to implant design and manufacturing. Having an understanding of the history and evolution of these implants will provide us with context in which to guide future implant design and clinical use. This review article provides a comprehensive overview of the evolution of early shoulder stabilization techniques and implants to the modern implants being used today.

Review of Latarjet (1954) on the treatment of recurrent shoulder dislocations

This classic discusses the original publication ‘Treatment of recurrent dislocation of the shoulder’ on the Latarjet procedure. This surgical technique that has become one of the basics in shoulder-stabilising surgery, introduced by Latarjet in 1954 in the journal Lyon Chirurgical. Inspired by publications of colleagues in the field of shoulder surgery, Latarjet introduced a technique that transfers the coracoid process to the anterior glenoid rim in patients with anterior shoulder instability. Although being outrun in popularity by the Bankart repair for several decades, improved knowledge regarding long-term outcomes, surgical techniques and patient characteristics such as bone loss and participation in contact sports has led to renewed interest in the Latarjet procedure. This especially accounts for patients with significant glenohumeral bone loss or patients with a previously failed soft tissue repairs. Whereas the increase in popularity has led to many studies focussing on various aspects, the 15 basics of the initial procedure have virtually remained unchanged.

Current Concepts in Rehabilitation for Traumatic Anterior Shoulder Instability

PURPOSE OF REVIEW

The objectives of this review are to evaluate the current evidence-based literature and concepts surrounding rehabilitation in patients with anterior shoulder instability injuries and surgical repair.

RECENT FINDINGS

The current literature evidence for shoulder rehabilitation for anterior shoulder instability and labral repair is limited. As a result, there are variations among surgeons and physical therapists in rehabilitation protocols after anterior shoulder instability injuries and repair. While general consensus on certain rehabilitation parameters exists, the evidence for the importance of rehabilitation and functional performance test for return to sport in future injury prevention is still lacking in literature. Rehabilitation after anterior shoulder instability injury and anterior labral repair is paramount in the injured or post-operative shoulder. Restoration of soft tissue mobility, dynamic glenohumeral joint stability, and balance and strength around the shoulder not only protect healing of injured or repaired soft tissues but also potentially minimizes future re-injury or recurrence risk.

Comparison of Magnetic Resonance Imaging and Computed Tomography Scans of the Glenoid Version in Anterior Dislocation of the Shoulder

The glenoid version is an important factor in the etiology of anterior dislocation of the shoulder and the planning of shoulder surgery. Few reports compare the magnetic resonance imaging (MRI) measurements of the glenoid version with those of computed tomography (CT). This study aimed to show that it is possible to use MRI instead of CT, which is accepted as the gold standard today for the evaluation of the glenoid version. A total of 55 patients with a history of 1 nonsurgically treated unilateral anterior dislocation of the shoulder who had both MRI and CT records for the dislocated shoulders constituted the study group. The glenoid version was measured in the axial plane on MRI and CT. Mean glenoid version measured by the observers was -1.6°±4.7° (95% confidence interval, -2.3° to -0.8°) and -1.8°±4.3° (95% confidence interval, -2.5° to -1.2°) by CT and MRI, respectively (P=.126). The evaluation of the CT and MRI measurements made by the 3 observers (X, Y, and Z) revealed no significant difference, as the P values of X CT - X MRI, Y CT - Y MRI, and Z CT - Z MRI were .550, .406, and .238, respectively. Interclass correlation among the 3 observers for CT and MRI was 0.996 and 0.981, respectively. The imaging methods of MRI and CT can be interchangeably used in the evaluation of the glenoid version in cases of anterior dislocation of the shoulder. [Orthopedics. 2017; 40(4):e687-e692.].

The importance of glenoid version in patients with anterior dislocation of the shoulder

BACKGROUND

Although increased retroversion of the glenoid has been shown to be an important factor in posterior instability of the shoulder, there are few studies reporting glenoid bone structure as a risk factor in anterior dislocation of the shoulder. This study aimed to compare glenoid version in patients with anterior dislocation of the shoulder and individuals in a control group with no shoulder problems before undergoing computed tomography and to assess a possible relationship between demographic characteristics and glenoid version angle.

METHODS

The study group comprised 63 patients (12 women and 51 men; mean age, 35.71 years) with 1 or multiple unilateral anterior dislocations of the shoulder (dislocated group), whereas 63 individuals (11 women and 52 men; mean age, 35.38 years) with no history of shoulder complaints and no signs of instability constituted the control group. The glenoid version angle was measured on an axial cut of the computed tomography scan.

RESULTS

The glenoid version angles on the dislocated side in the study group were significantly more anteverted than those of the dominant (P < .001) and nondominant (P = .023) shoulders of the control group. The version angles of dislocated shoulders significantly differed from those of nondislocated shoulders of both men (P = .041) and women (P = .049). There was no significant relationship between the glenoid version angle on the dislocated side and dislocation mechanism (P = .883), age group (P = .356), or number of dislocations (P = .971).

CONCLUSIONS

Glenoid version is an important factor for the development of anterior dislocation of the shoulder.

History of surgical intervention of anterior shoulder instability

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Arthroscopic Bankart repair: Have we finally reached a gold standard?

Traditionally, surgical stabilization of the unstable shoulder has been performed through an open incision. Arthroscopic Bankart repair with suture anchors is now widely considered the treatment of choice for anterior shoulder instability in patients who have failed conservative management. Many different factors have now been elucidated for adequate treatment of glenohumeral instability. Because of technical advances in instability repair combined with an increased understanding of factors that lead to recurrent instability, the outcomes following arthroscopic Bankart repair have significantly improved and approach those of open techniques.

Bankart arthroscopic procedure: comparative study on use of double or single-thread anchors after a 2-year follow-up

OBJECTIVE

To compare the use of anchors with double and single-thread loading in the single-row Bankart arthroscopic procedure.

METHODS

252 patients (258 shoulders) underwent Bankart arthroscopic surgery with evaluation after a minimum follow-up of 2 years. They underwent repairs either using anchors with single loading of a high-resistance non-absorbable braided thread (206 shoulders; group AS) or using double loading of thread with the same characteristics (52 shoulders; group AD). The patients were evaluated using the UCLA and Carter-Rowe scales. The patients' return to sports activity and recurrences were also compared.

RESULTS

There was no significant difference between the groups regarding the surgical failure rate (group AS 5.8%; group AD 7.7%; p = 0.62). Group AS presented a better mean Carter-Rowe score (group AS 94.4; group AD 88.6; p < 0.05) and greater return to the same sports level (group AS 79.1; group AD 72.1; p < 0.05).

CONCLUSION

Use of anchors with double thread loading did not show any clinical advantage for arthroscopic repair of traumatic anterior shoulder instability, in relation to use of single-thread anchors, over a 2-year follow-up.

Nonoperative and postoperative rehabilitation for glenohumeral instability

The glenohumeral joint is an inherently unstable joint that relies on the interaction of the dynamic and static stabilizers to maintain stability. Disruption of this interplay or poor development of any of these factors may result in instability, pain, and a loss of function. Rehabilitation will vary based on the type of instability present and the key principles described. Whether a course of nonoperative rehabilitation is followed or the patient presents postoperatively, a comprehensive program designed to establish full ROM and balance capsular mobility, in addition to maximizing muscular strength, endurance, proprioception, dynamic stability, and neuromuscular control is essential. A functional approach to rehabilitation using movement patterns and sport-specific positions along with an interval sport program will allow a gradual return to athletics. The focus of the program should minimize the risk of recurrence and ensure that the patient can safely return to functional activities.

Balloon osteoplasty--a new technique for minimally invasive reduction and stabilisation of Hill-Sachs lesions of the humeral head: a cadaver study

PURPOSE

Traumatic shoulder dislocation may be complicated by concomitant bony injury of the glenoid rim or the humeral head. In Hill-Sachs lesions, reconstruction techniques vary widely and range from open reduction to tendon transposition or humeral head derotation. These operations are extensive and have questionable outcomes. With the expertise from vertebral compression fracture reduction by kyphoplasty, we examined in a cadaver feasibility study whether reduction of the Hill-Sachs lesion via hydraulic lift might be an anatomical and minimally invasive treatment option. We postulated that the use a of a balloon- assisted kyphoplasty reduction could achieve almost anatomical correction of the defect.

METHODS

We created Hill-Sachs lesions in six humeral specimens and performed a computed tomography (CT) scan before and after reduction with the kyphoplasty system. The entry point at the greater tuberosity and balloon positioning was visualised by fluoroscopy. The size of the Hill-Sachs lesion before and after reduction was measured using CT scans in the axial orientation.

RESULTS

Using the balloon kyphoplasty system, we achieved a statistically significant reduction (80 % ) of the Hill-Sachs lesion.

CONCLUSION

In a preliminary cadaver study we show that using a balloon kyphoplasty system might be an alternative treatment option for Hill-Sachs lesions, with reduced collateral damage that can occur with other minimally invasive techniques. Future work is needed to evaluate the technique under arthroscopic conditions.

FUNCTIONAL ASSESSMENT OF ARTHROSCOPIC REPAIR FOR RECURRENT ANTERIOR SHOULDER INSTABILITY

Objective: To clinically and radiologically evaluate patients who underwent arthroscopic surgical treatment for anterior shoulder instability by means of the Bankart technique, using metal anchors. Methods: This was a retrospective study on 49 patients who underwent arthroscopic repair of anterior shoulder instability between 2002 and 2007. The patients were evaluated using the Carter-Rowe score and the Samilson and Prieto classification. The mean age at the time of surgery was 30 years. The mean length of follow-up was 42.7 months (ranging from 18 to 74). 85% of the patients were male. Results: The mean Carter-Rowe score was 83 points (ranging from 30 to 100) including 31 excellent results, 7 good, 3 fair and 8 poor. Recurrent dislocation was observed in 16% (8 patients), and 37.5% of them were of traumatic origin. Joint degeneration was present in 32.5% of the cases, including 5 cases of grade 1, 6 cases of grade 2 and 2 cases of grade 3. The average loss of external rotation was 12° and the loss of anterior elevation was 8°. There was a statistically significant relationship (p < 0.05) between arthritis and age at first dislocation, age at surgery and crackling. 92% of the patients reported high degrees of satisfaction after the procedure. Among the complications, there were two cases of stiff shoulder, one patient with prominence of the synthesis material and one case of anchor loosening. Conclusion: Arthroscopic repair of anterior shoulder instability using metal anchors was shown to be effective, with a low complication rate.

The role of arthroscopy in the revision of failed Latarjet procedures

Glenohumeral instability is an intrinsic pathological condition of the shoulder, owing to its ample range of mobility that predisposes this joint to a somewhat limited degree of stability. Several techniques have been employed for the treatment of instability. Among these, one is the Latarjet procedure, recommended for cases of substantial bone deficit on the humeral head or on the anterior region of the glenoid. Such technique gives generally good, long-term results, considering the low incidence of recurrence. However, potential complications such as glenohumeral arthrosis, absorption of the bone block, breakage, malpositioning or mobilization of the screws, infections, neurological or vascular complications can be serious. Moreover, as a result of further severe trauma, the shoulder can become again globally unstable. In such cases, the question arises of which technique to employ in surgical revision, since the Latarjet procedure determines substantial subversion of glenohumeral anatomy. The aim of the study was the analysis of arthroscopical treatment after failure of a Latarjet procedure and to describe the related definitive results. During the period between January 2000 and June 2007, we treated 17 patients (18 shoulders) using arthroscopy, following failure of an open Latarjet surgical procedure. One patient was operated bilaterally. Clinical revision according to the Constant Score, ROWE, ASES, UCLA and the VAS scale for pain evaluation was carried out during follow-up examination after an average period of 5 years and 9 months (min. 2 years-max. 9 years) from latest surgery. The system of evaluation according to the Constant Score indicated an average score of 78.4/100 at follow-up examination; UCLA indicated 27.2/35; ASES 99.6/120; ROWE 75.2/100. With regard to pain, the VAS Scale indicated an average score of 2.9/10. As criteria for relapse, we considered classic cases of dislocation and subluxations, or sprains with subluxation, and subjectively experienced apprehension and pain to a degree that seriously inhibited the patient's daily life. The incidence of relapse following the final surgical operation (taking into consideration both frank dislocations and subluxations) was 16.7%. At clinical revision, one patient showed dislocation due to relatively modest trauma approximately 1 year following the second surgery (5.6%). Episodes of subluxation or sprains continued in 2 shoulders (11.1% relapse). In 11 cases (61%), return to sports activities was achieved. Arthroscopy technique using anchors and sutures can, in selected cases, lead to satisfactory results, allowing, by means of minimal surgical invasion, identification and treatment also of intra-articular lesions, where associated.

The American Society of Shoulder and Elbow Therapists' consensus rehabilitation guideline for arthroscopic anterior capsulolabral repair of the shoulder

This manuscript describes the consensus rehabilitation guideline developed by the American Society of Shoulder and Elbow Therapists. The purpose of this guideline is to facilitate clinical decision making during the rehabilitation of patients following arthroscopic anterior capsulolabral repair of the shoulder. This guideline is centered on the principle of the gradual application of stress to the healing capsulolabral repair through appropriate integration of range of motion, strengthening, and shoulder girdle stabilization exercises during rehabilitation and daily activities. Components of this guideline include a 0- to 4-week period of absolute immobilization, a staged recovery of full range of motion over a 3-month period, a strengthening progression beginning at postoperative week 6, and a functional progression for return to athletic or demanding work activities between postoperative months 4 and 6. This document represents the first consensus rehabilitation guideline developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients following arthroscopic anterior capsulolabral repair of the shoulder.

Arthroscopic stabilization for first-time versus recurrent shoulder instability

PURPOSE

The purpose of this study was to systematically review the evidence on the outcomes of arthroscopic repair for anterior shoulder instability in first-time dislocators when compared with patients with recurrent instability.

METHODS

We designed a systematic review with a specific methodology to investigate the outcomes of surgery for those with only a first-time dislocation versus those who underwent surgery after multiple instability events. We performed a literature search from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials. Key words included the following: first time, primary shoulder, or recurrent shoulder instability, shoulder dislocation, Bankart repair, arthroscopic Bankart repair, and labral repair. The inclusion criteria were cohort studies (Level I to II) that evaluated the outcomes of patients undergoing arthroscopic stabilization after the first dislocation or multiple recurrent episodes. Studies that lacked a comparison group or were retrospective (Level III studies or higher) were excluded.

RESULTS

There were 15 studies that met the inclusion criteria and were included in the final analysis: 5 in the first-time dislocation group and 10 in the recurrent instability group. Study design, patient demographics, mean number of dislocations, surgical technique, and rehabilitation protocol, as well as subjective and objective outcome measures, were recorded.

CONCLUSIONS

There were no differences in recurrence or complication rate among patients undergoing surgery after the primary dislocation when compared with those undergoing surgery after multiple recurrent episodes. Clinical outcome measures significantly improved within all independent studies from preoperatively to postoperatively. However, because of variation in the outcome measurement tools used, no direct comparison between the study groups could be performed. Additional randomized controlled studies are needed to compare the functional outcome, quality of life, and ability to return to preinjury activity level among patients undergoing early versus delayed repair for anterior shoulder instability.

Revision open Bankart surgery after arthroscopic repair for traumatic anterior shoulder instability

BACKGROUND

Only a few studies have provided homogeneous analysis of open revision surgery after a failed arthroscopic Bankart procedure.

HYPOTHESIS

Open Bankart revision surgery will be effective in a failed arthroscopic anterior stabilization but inevitably results in a loss of range of motion, especially external rotation.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twenty-six shoulders that went through traditional open Bankart repair as revision surgery after a failed arthroscopic Bankart procedure for traumatic anterior shoulder instability were enrolled for this study. The mean patient age at the time of revision surgery was 24 years (range, 16-38 years), and the mean duration of follow-up was 42 months (range, 25-97 months).

RESULTS

The preoperative mean range of motion was 173 degrees in forward flexion and 65 degrees in external rotation at the side. After revision surgery, the ranges measured 164 degrees and 55 degrees, respectively (P = .024 and .012, respectively). At the last follow-up, the mean Rowe score was 81 points, with 88.5% of the patients reporting good or excellent results. After revision surgery, redislocation developed in 3 shoulders (11.5%), all of which had an engaging Hill-Sachs lesion and associated hyperlaxity (2+ or greater laxity on the sulcus sign).

CONCLUSION

Open revision Bankart surgery for a failed arthroscopic Bankart repair can provide a satisfactory outcome, including a low recurrence rate and reliable functional return. In open revision Bankart surgery after failed stabilization for traumatic anterior shoulder instability, the surgeon should keep in mind the possibility of a postoperative loss of range of motion and a thorough examination for not only a Bankart lesion but also other associated lesions, including a bone defect or hyperlaxity, to lower the risk of redislocation.

Effects of posterior-inferior capsular plications in range of motion in arthroscopic anterior Bankart repair: a prospective randomized clinical study

The effects of posterior plications associated with anterior shoulder instability surgery are still unclear both on shoulder range of motion (ROM) and on recurrence rate. The objective of this randomized study is to evaluate the influence of posterior-inferior plications, performed in association with repair of anterior Bankart lesion, on gleno-humeral (GH) range of motion. In a 24-month period, 40 patients were prospectively enrolled in this study. The criteria for inclusion were age between 17 and 40 years, traumatic unidirectional instability, no previous shoulder surgery, no more than three episodes of dislocation, no relevant glenoid bone deficiency, no clinical evidence of pathological anterior inferior laxity (measured with external rotation with the arm at the side inferior to 90 degrees and Gagey sign negative) and arthroscopic finding of isolated anterior Bankart lesion. A total of 20 patients (group A) were randomized to treat Bankart lesion using three bioadsorbable anchors loaded with a #2 braided polyester suture. In 20 randomized patients (group B) two posterior-inferior capsular plications performed with a #1 polidioxanone suture without any capsular shift were added to the same anterior capsulorraphy performed in group A. Postoperative rehabilitation protocol was the same for all 40 patients. Patients were examined preoperatively and at a 2-year follow-up by a single independent expert physician unaware of the surgical procedure. GH ROM, Constant, UCLA and ASES rating scores as well as recurrence of instability were recorded. At follow-up, forward flexion (FF) decreased by a mean value of 14.5 degrees (median -10 degrees ; range -5 degrees to -35 degrees ; P < 0.001) in group B and increased by a mean value of 3.5 degrees (median 0 degrees ; range -25 degrees to 40 degrees ; P < 0.312) in group A; external rotation with arm adducted (ER1) increased by a mean value of 1.8 degrees (median 0 degrees ; range -15 degrees to 30 degrees ; P < 0.924) in group B, and increased by a mean value of 2.6 degrees (median 2.5 degrees ; range -38 degrees to 40 degrees ; P < 0.610) in group A; external rotation with arm abducted at 90 degrees (ER2) decreased by a mean value of 2.9 degrees (median 0 degrees ; range: -20 degrees to 10 degrees ; P < 0.161) in group B and increased by a mean value of 0.7 degrees (median 0 degrees ; range -30 degrees to 25 degrees ; P < 0.837) in group A; the IR2 decreased by a mean value of 2.4 degrees (median -3.5 degrees ; range -15 degrees to 10 degrees ; P < 0.167) in group B and increased by a mean value of 2.2 degrees (median 0 degrees ; range -20 degrees to 30 degrees ; P < 0.456) in group A. The UCLA mean score gains by 43.1% (median 40; P < 0.001) relatively, and of 45.2% relatively (median 40; P < 0.001), respectively, in group B and A, ASES mean score relatively gains by 21.7% (median 21.2%; P < 0.001) in group B, and of 19.2% (median 18.9%; P < 0.001) in group A, and Constant mean score improves by 20.2% (median 16.5; P < 0.001) in group B, and 10.2% (median 8.4%; P < 0.001) in group A. Thus, the only statistical significant differences were the reduction of forward flexion in group B and the improvements of the scores in both groups. No recurrence of instability was found in the plicated group, while in the non-plicated group we had one traumatic recurrence. In conclusion, arthroscopic posterior-inferior plications associated with a Bankart lesion repair in a selected group of patients seem to reduce only FF, without any effect on rotation. A longer follow-up and a larger number of patients are needed to give definitive conclusions on the benefit to the recurrence rate.

Revision arthroscopic capsulolabral reconstruction for recurrent instability of the shoulder

We have investigated the outcome of arthroscopic revision surgery for recurrent instability of the shoulder after failed primary anterior stabilisation. We identified 40 patients with failed primary open or arthroscopic anterior stabilisation of the shoulder who had been treated by revision arthroscopic capsulolabral reconstruction and followed up for a mean of 36 months (12 to 87). There were 34 men and six women with a mean age of 33.1 years (15 to 48). Details of the patients, the technique of the primary procedure, the operative findings at revision and the clinical outcome were evaluated by reviewing the medical records, physical examination and the use of the Western Ontario shoulder instability index score, the American Shoulder and Elbow Surgeons score and the health status questionnaire 12.

Recurrent instability persisted in four patients after the revision arthroscopic procedure. At the final follow-up, the mean American Shoulder and Elbow Surgeons score was 81.1 (17.5 to 99.5) and the mean Western Ontario shoulder instability index score was 68.2 (20 to 98.2). Quality-of-life scoring showed good to excellent results in most patients.

Arthroscopic revision capsulolabral reconstruction can provide a satisfactory outcome in selected patients for recurrent instability of the shoulder provided that no large Hill-Sachs lesion is present.

Results of arthroscopic capsulolabral repair: Bankart lesion versus anterior labroligamentous periosteal sleeve avulsion lesion

PURPOSE

The purpose of this study was to evaluate the results of arthroscopic capsulolabral repair for traumatic anterior shoulder instability and to compare the outcome in patients who have Bankart lesions versus those with anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions.

METHODS

This study included 99 patients (93 shoulders), 72 male and 17 female, with a mean age of 32 years, who underwent arthroscopic Bankart repair for traumatic, recurrent anterior shoulder instability, by use of suture anchors. In 67 shoulders (72%) a discrete Bankart lesion was repaired, and in 26 shoulders (28%) an ALPSA lesion was repaired. The 2 groups were analyzed with regard to the number of preoperative dislocations and number of postoperative recurrences.

RESULTS

At a mean follow-up of 47 months (range, 24 to 98 months), recurrence of instability was documented in 10 shoulders (10.7%). Of the shoulders, 5 had Bankart lesions (7.4%) and 5 had ALPSA lesions (19.2%) (P = .0501). The mean number of dislocations or subluxations before the index surgery was significantly higher in the ALPSA group (mean, 12.3 [range, 2 to 57]) than in the Bankart group (mean, 4.9 [range, 2 to 24]) (P < .05). However, there were no significant differences in the number of anchors used, incidence of minor glenoid erosion, or incidence of bony Bankart lesions between the groups (P > .05 for all).

CONCLUSIONS

Patients with ALPSA lesions present with a higher number of recurrent dislocations than those with discrete Bankart lesions. In addition, the failure rate after arthroscopic capsulolabral repair is higher in the ALPSA group than in the Bankart group.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Relationships of the musculocutaneous nerve and the coracobrachialis during coracoid abutment procedure (Latarjet procedure)

PURPOSE

The aim of this study was first to define first the anatomical relationships between the musculocutaneous nerve and the coracobrachialis, and then the induced modifications of these relationships by a preglenoid transposition of the vertical part of the coracoid process.

MATERIALS AND METHODS

Twenty-one embalmed adult trunks and upper limb were dissected. First the coracobrachialis and the musculocutaneous nerve were identified through a deltopectoral approach. We measured the distances between the lateral cord of the brachial plexus and the entry point of the nerve, between the inferior tip of the tip of the coracoid process and the penetration of the nerve or its twigs, and finally the angle between the general axis of the coracobrachialis and the axis of the musculocutaneous nerve. The same measures were performed after the coracoid bone block abutment.

RESULTS

Proximal motor branches destined to the coracobrachialis varied from 0 to 3. Mean distance between the lateral cord of the brachial plexus and entry point of the nerve into the muscle was 47.2 mm before and 48.43 mm after the coracoid transfer. Mean angulations between the nerve and the muscle was 121 degrees before and 136 degrees after the transfer of the coracoid process. Mean distance between the inferior tip of the coracoid process and entry point of the nerve into the muscle was 55.7 mm, reduced to 48.6 mm after the coracoid transposition. Finally, the distance between the tip of the coracoid and the first motor twig entering the coracobrachialis was less than 50 mm in 75% of the cases with a mean value of 40.6 mm.

CONCLUSIONS

Lesion of the musculocutaneous nerve is a known complication of the coracoid bone block abutment procedure (Latarjet-Bristow). From this study we know that they are due to lengthening of the nerve and modification of the penetration angle of the nerve into the coracobrachialis. We also infer that some motor nerve destined to the coracobrachialis might be damaged during the proximal medial release of the muscle after the detachment of the pectoralis minor muscle.

Arthrosopic knot pushers. Does one size fit all?

Little is known about how knot-pusher design affects arthroscopic knot tying. In our practice, we observed the knot-pusher riding onto the arthroscopic knot at the point of maximum tightening. This can lead to snagging of the knot, which is undesirable as it may lead to loosening of, or damage to the knot. The aim of this study is to determine the optimum size of a knot-pusher to efficiently push the knot without overriding or snagging it. We used an apparatus to model arthropcopic knot tying. Ten examples each of the Duncan loop were tied under controlled conditions of load using one polydioxanone (PDS) monofilament absorbable suture (Ethicon, Livingston, UK), two Ethibond, two Fibrewire and two Panacryl. The loop of the knot was then secured and a 50 N force applied to tension the knot. The suture diameter was measured. Then the knot diameter was measured in two planes using an analogue micrometer. The internal diameter of a Mitek knot-pusher was measured. The mean maximum diameter for each knot was respectively PDS, 2.061 +/- 0.13 mm; Panacryl, 1.907 +/- 0.14 mm; Ethibond, 1.717 +/- 0.16 mm and Fibrewire, 1.654 +/- 0.14 mm. There were significant differences in size between knots tied with different materials except between Ethibond and Fibrewire where the difference was not significant. For each set of knots the smallest maximum knot diameter observed was identified. This was respectively PDS, 1.92 mm; Ethibond, 1.476 mm; Fibrewire, 1.488 mm and Panacryl, 1.715 mm. The internal diameter of a Mitek knot-pusher was found to be 1.95 mm. The current Mitek knot-pusher appears to be well suited to one PDS and two Panacryl. It appears less ideal for two Ethibond and two Fibrewire. One knot-pusher does not fit all and we suggest that different knot-pushers be used for different suture materials.

Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations

A systematic search of the literature published between January 1985 and February 2006 identified 62 studies which reported the results of arthroscopic procedures for chronic anterior shoulder instability or comparisons between arthroscopic and open surgery. These studies were classified by surgical technique and research methodology, and when appropriate, were included in a meta-analysis. The failure rate of arthroscopic shoulder stabilisation using staples or transglenoid suture techniques appeared to be significantly higher than that of either open surgery or arthroscopic stabilisation using suture anchors or bio-absorbable tacks. Arthroscopic anterior stabilisation using the most effective techniques has a similar rate of failure to open stabilisation after two years.

The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability

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

Outcome after failed traumatic anterior shoulder instability repair with and without surgical revision

The purpose of this study was to evaluate the incidence and reasons of recurrent instability in patients with traumatic anterior shoulder instability and to document the clinical results with regard to the number of stabilizing procedures. Twenty-four patients with failed primary open or arthroscopic anterior shoulder stabilization were followed for a mean of 68 (36-114) months. Following recurrence of shoulder instability, eight patients chose not to be operated on again, whereas 16 underwent repeat stabilization. A persistent or recurrent Bankart lesion was found in all 16 patients and concomitant capsular redundancy in 4. After the first revision surgery, further instability occurred in 8 patients, and 6 of them were stabilized a third time. Only 7 patients (29%) achieved a good or excellent result according to the Rowe score. All shoulder scores improved after revision stabilization. However, the number of stabilizing procedures adversely affected the outcome scores, as well as postoperative range of motion and patient satisfaction. Recurrent instability after a primary stabilization procedure represents a difficult diagnostic and surgical challenge, and careful attention should be paid to address persistent or recurrent Bankart lesions and concomitant capsular reduncancy. A satisfying functional outcome can be expected mainly in patients with one revision surgery. Further stabilization attempts are associated with poorer objective and subjective results.

Allografts in the Treatment of Athletic Injuries of the Shoulder

As allogeneic musculoskeletal tissue is readily available, has minimal limitation in size or shape, and carries no donor site morbidity, it has become attractive for use in reconstructive shoulder surgery. Allograft is a viable option for treating osseous defects associated with glenohumeral instability and has been shown to achieve a stable shoulder with good clinical outcomes. Although there are mixed results on the use of allograft as rotator cuff augments or substitutes, new commercially processed materials such as GraftJacket are being tested to address the high failure rates associated with massive rotator cuff repair. Interposition arthroplasty as a treatment for glenohumeral arthritis in the young and active patient is a novel concept in which the arthritic glenoid is biologically resurfaced. Satisfactory results have been described using lateral meniscus and Achilles tendon allograft. Despite the promising reports on the use of allograft in reconstructive shoulder surgery, most of the published literature exists as retrospective, case reports. Additional large, controlled research is needed to prove the efficacy and safety of allograft tissue in the treatment of athletic injuries of the shoulder.

Revision arthroscopic shoulder instability repair

PURPOSE

The purpose of this study was to report on a difficult patient population and to critically evaluate the role of revision arthroscopic stabilization surgery.

METHODS

Eighteen patients with failed traumatic instability repairs were treated with revision arthroscopic labral fixation and plication with a mean follow-up of 29.7 months (range, 24 to 48 months). There were 15 male patients and 3 female patients with a mean age of 28.6 years (range, 15 to 50 years). Of the 18 patients, 9 were Workers' Compensation cases. The 18 patients had a mean of 1.55 surgeries before our revision surgery, with 9 having a component of thermocapsular shrinkage. The patients' characteristics, operative techniques, and findings were recorded, and their clinical outcome was critically evaluated (via physical examination, visual analog pain scale, Simple Shoulder Test, American Shoulder and Elbow Surgeons score, and Short Form 12).

RESULTS

The revision surgery incorporated a 4-portal technique via a mean of 4.6 suture anchors and 3 plication stitches, and 15 patients received a rotator interval closure. At the follow-up evaluation, 13 patients had satisfactory results whereas 5 cases were considered clinical failures (with recurrent instability in 3 and pain in 2). There was clinically significant improvement in pain score (6 preoperatively v 2 postoperatively, P = .0001), Simple Shoulder Test score (6 preoperatively v 10 postoperatively, P = .001), and American Shoulder and Elbow Surgeons score (50 preoperatively v 76 postoperatively, P = .001). Of the 9 Workers' Compensation patients, 5 were able to return to their original work.

CONCLUSIONS

Arthroscopic revision instability repair by use of a combination of suture anchors, plication stitches, and rotator interval closure can result in a satisfactory outcome in selected patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic Bristow procedure for anterior instability in shoulders with a stretched or deficient capsule: the "belt-and-suspenders" operative technique and preliminary results

PURPOSE

We report the results of a new technique consisting of a combined arthroscopic Bankart repair associated with a transfer of the coraco-biceps tendon to reinforce the deficient anterior capsule by lowering the subscapularis.

METHODS

The procedure combines 2 parts: an arthroscopic Bankart repair, which recreates the glenoid concavity and retensions the inferior glenohumeral ligament (i.e., "the belt," or intra-articular ligamentoplasty), and an arthroscopic transfer of the conjoined tendon with a coracoid fragment, to reinforce the stretched or torn inferior glenohumeral ligament (i.e., "the suspenders," or extra-articular ligamentoplasty). The coracoid fragment is exteriorized, shaped, and calibrated, and a tenodesis of the coraco-biceps tendon is performed above the subscapularis tendon by fixing the coracoid fragment with a bioabsorbable interference screw in a glenoid socket in the scapular neck. Thirty-six patients were available for clinical and radiographic review with a minimum 1-year follow-up.

RESULTS

Of the patients, 28 (78%) were very satisfied, 5 (14%) were satisfied, and 3 (8%) were disappointed. In comparison to the contralateral shoulder, postoperative mobility revealed no loss of active anterior elevation, a mean deficit of 9 degrees in external rotation with the arm at the side, a mean deficit of 15 degrees in external rotation in abduction, and no loss of internal rotation. The mean Walch-Duplay score was 87 points. Failures occurred in 3 patients (8%) who presented with recurrent instability.

CONCLUSIONS

This new intra- and extra-articular combined technique constitutes an alternative in the treatment of anterior shoulder instability in patients with deficient or stretched anterior capsule. It combines the theoretic advantages of the Bristow bone-block procedure and the arthroscopic Bankart repair while eliminating the potential disadvantages of each.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Patients undergoing stabilization surgery for recurrent, traumatic anterior shoulder instability commonly have restricted passive external rotation

An important component in the surgical treatment of recurrent anterior shoulder dislocations is the Bankart repair. This is often supplemented with ligament plication for perceived laxity. The glenohumeral ligaments define translational laxity and restrict glenohumeral range of motion. The purpose of this study was to measure the external rotation (ER) range of motion of patients under anesthesia for glenohumeral stabilization surgery. A blinded observer measured bilateral shoulder ER in 15 patients by use of a standardized torque and goniometry. ER in the unstable shoulder with the arm abducted 90 degrees averaged 14 degrees less than that in the uninjured shoulder, and this was statistically significant. There was a significant loss of 11 degrees ER in the unstable shoulder with the arm at the side. The findings indicate that the glenohumeral joint in patients with a Bankart lesion is commonly rotationally stiff.

Revision of failed arthroscopic bankart repairs

BACKGROUND

The results following open revision surgery following a failed arthroscopic Bankart procedure are not well documented.

PURPOSE

To evaluate the results of patients with a failed arthroscopic Bankart repair treated with a traditional, open Bankart repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Thirty patients (28 male and 2 female) who had a mean age of 24 years (range 15-36) at the time of operation were evaluated. The mean interval from the time of the operation to the final follow-up was 46 months (range 24-55). The rating systems of Rowe and the University of California at Los Angeles (UCLA) were recorded preoperatively and at the time of the final evaluation.

RESULTS

After open repair, mean modified Rowe scores improved from 25 preoperatively to 84.2 points. The results were excellent in 2 (6.7%), good in 24 (80%), and fair in 4 (13.3%); there were no poor results. The UCLA shoulder score improved from a mean of 17 points preoperatively to 29 points (P = .001 for all comparisons). Twenty-six patients (87%) did not have an anchor placement inferior to the 4-o'clock position for a right shoulder or the 8-o'clock position for the left shoulder after the index arthroscopic repair. There were no rotator interval closures performed at the index arthroscopic Bankart repair, and 10 patients (33%) required an interval closure at the open revision procedure. Twenty-five patients (83%) immobilized the operated arm in a sling for less than 2 weeks following the index arthroscopic repair.

CONCLUSION

Patients with failed arthroscopic Bankart repairs can be successfully treated with a revision, open Bankart repair. Inadequate postoperative immobilization, large rotator intervals, and improper anchor placement are possible risk factors that may increase the incidence of failure of an arthroscopic Bankart repair.

Arthroscopic Bankart repair using Knotless or BioKnotless suture anchors: 2- to 7-year results

PURPOSE

This study was performed to evaluate the results of arthroscopic Bankart repair, by use of Knotless or BioKnotless suture anchors (DePuy Mitek, Raynham, MA), for traumatic anterior shoulder instability.

METHODS

We performed a retrospective evaluation of 73 consecutive patients with traumatic anterior instability of the shoulder treated with arthroscopic Bankart repair by use of metallic Knotless or BioKnotless suture anchors. No additional capsular plication, thermal modification, or interval closure was performed in any patient. The senior author performed all procedures. Independent examiners performed physical examinations. Self-assessment questionnaire evaluations were completed, and preoperative and postoperative American Shoulder and Elbow Surgeons and Rowe scores are reported.

RESULTS

Results at a minimum of 2 years' follow-up (range, 2 to 7 years) are reported for 72 patients (57 male and 15 female patients) available for follow-up evaluation. One patient was lost to follow-up. Of the patients, 5 (6.9%) had post-repair instability (3 dislocations and 2 subluxations). The mean postoperative loss of external rotation, at 90 degrees of abduction, was 1 degrees . All patients who had postoperative instability were aged 22 years or younger. The post-repair instability rate in this age group was 13.5% (5/37). No failures occurred in patients aged over 22 years. Of the post-repair dislocations, 3 (7.5%) were in patients involved in contact or collision sports. All 5 failures occurred early, within 2 years of the index surgery. Revision arthroscopic repairs via Knotless or BioKnotless suture anchors were performed in 3 of 4 patients, and a Latarjet procedure was also performed in the fourth patient. The fifth patient refused further intervention. All of the revision shoulders remained stable at the latest follow-up, 3 of which had at least 2 years of follow-up.

CONCLUSIONS

Arthroscopic Bankart repair via Knotless or BioKnotless suture anchors showed a recurrence rate of 6.9%. Using Knotless or BioKnotless suture anchors provides satisfactory results with a low recurrence rate, minimal loss of motion, and reliable functional return, even in contact and collision athletes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The "purse-string" technique: an arthroscopic technique for stabilization of anteroinferior instability of the shoulder with early and medium-term results

PURPOSE

We report the early and midterm results of the "purse-string" technique, a simple, new arthroscopic technique for stabilization of anteroinferior instability of the glenohumeral joint that addresses both the Bankart lesion and capsular stretching.

METHODS

The patients comprised 36 individuals (37 shoulders), with a mean age of 26 years, who had recurrent anteroinferior post-traumatic instability as a result of a traumatic Bankart lesion. They had sustained a mean of 5 dislocations per shoulder (range, 1 to 11). The cohort included 5 professional and 6 semiprofessional athletes, all of whom were involved in collision or overhead sports. A purse-string suture anchor at the 4-o'clock position was used to ensure a purse-string effect in tightening the capsule in the inferior-superior plane and creation of anterior glenoid bumper. All of the patients were assessed by an independent investigator (T.M.) at a mean of 36 months (range, 27 to 87 months) after surgery.

RESULTS

Postoperatively, the mean Rowe score was 93 (range, 55 to 100), the mean Walch-Duplay score was 93 (range, 70 to 100), and the mean Constant score was 97 (range, 77 to 100). Of the patients, 97% returned to the same sport that they had played before injury. Furthermore, 66% of patients returned to their preinjury level of sports, and all of the professional athletes resumed full activities. One patient continued to have symptoms of instability, and one patient had a further dislocation after a new traumatic event.

CONCLUSIONS

The early and medium-term results obtained are very encouraging, with a rate of failure of only 5.4%, a high level of return to preinjury sporting activities (with 97% of patients returning to the same sport and 66% returning to their preinjury level of sports), and a high patient satisfaction rate (with excellent or good results in 94% of patients).

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Long-term results of arthroscopic Bankart repair with a bioabsorbable tack

BACKGROUND

Short-term to midterm data are available on arthroscopic shoulder stabilization using bioabsorbable tacks or suture anchors. It remains unknown whether these techniques can equal the success of open Bankart repair in the long term.

PURPOSE

To assess the long-term outcome of arthroscopic Bankart repair using bioabsorbable tacks in patients with traumatic anterior shoulder instability with a minimum follow-up of 7 years.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Treatment outcomes were determined prospectively according to the Rowe score and retrospectively according to the Constant and American Shoulder and Elbow Surgeons scores. Included in this study were 18 consecutive patients with a mean age of 26.8 years (range, 16-62 years) who underwent arthroscopic Bankart repair using bioabsorbable tacks for traumatic anterior shoulder instability. The study group consisted of 14 male and 4 female patients. The mean follow-up was 8.7 years (range, 7.0-9.8 years).

RESULTS

One patient had recurrent dislocations requiring further surgery, for an overall failure rate of 5.6%. An additional patient had 1 traumatic subluxation episode within the first postoperative year that did not recur. According to the Rowe score, which increased to 90.3 (17.8) from 32.8 (8.3) points preoperatively, 15 patients (83.3%) achieved a good or excellent result. The mean Constant score was 91.3 (SD, 6.9) points, and the mean American Shoulder and Elbow Surgeons score was 92.1 (SD, 6.9) points postoperatively. A return to the preinjury level of sports competition was reported by 64% of patients. No signs of synovitis occurred in any patient postoperatively.

CONCLUSION

Arthroscopic Bankart repair for the treatment of recurrent traumatic anterior shoulder instability repair using bioabsorbable tacks offers reliable results with respect to failure rate, range of motion, and shoulder function during a minimum follow-up of 7.0 years. In contrast to previous reports on arthroscopic Bankart repair, results did not deteriorate during follow-up.

Quantitative assessment of glenohumeral translation after anterior shoulder dislocation and subsequent arthroscopic bankart repair

BACKGROUND

During the past decade, developments in arthroscopic technology have made arthroscopic repair of labral lesions feasible. However, results with the use of the transglenoid suture technique, or with the use of bioabsorbable tacks, have remained variable in the literature, and the recurrence rates are still inferior to those of open Bankart repair.

HYPOTHESIS

Arthroscopic Bankart repair with suture anchors can re-create translational and rotational range of motion of the intact glenohumeral joint, and the number of preoperative dislocations has an influence on the result.

STUDY DESIGN

Controlled laboratory study.

MATERIALS

Twelve cadaveric shoulders were tested in a robot-assisted shoulder simulator. Anterior and posterior translation and external rotation were measured for intact, dislocated (shoulders were randomly selected to 1 of 3 groups, which were dislocated 1, 3, or 7 times), and repaired conditions at 0 degrees and 90 degrees of glenohumeral elevation.

RESULTS

After shoulder dislocation, a significant increase was found in translation and rotation, confirming the creation of a traumatic shoulder instability model. Further testing of the specimen revealed that translational and rotational ranges of motion were reduced by arthroscopic Bankart repair at both testing positions. External rotation was decreased significantly at 0 degrees and 90 degrees of abduction. No significant differences were found between the 3 dislocation groups.

CONCLUSION

The results demonstrate a sufficient biomechanical performance of arthroscopic Bankart repair using suture anchors in a traumatic anterior shoulder instability model. With the numbers available, no relationship was found between the number of dislocations and the postoperative result concerning translational or rotational motion.

CLINICAL RELEVANCE

Glenohumeral translation and rotation after arthroscopic Bankart repair with use of suture anchors approached near normal values, confirming the clinical success of this technique.