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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

Results After Arthroscopic Bankart Repair in Contact Athletes Should Not Be Reported Globally Because of the High Variability in Recurrences Among the Different Contact or Collision Sports: A Systematic Review

PURPOSE

To describe and compare the recurrence rates in contact or collision (CC) sports after arthroscopic Bankart repair (ABR) and to compare the recurrence rates in CC versus non-collision athletes after ABR.

METHODS

We followed a prespecified protocol registered with PROSPERO (registration No. CRD42022299853). In January 2022, a literature search was performed using the electronic databases MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials), as well as clinical trials records. Clinical studies (Level I-IV evidence) that evaluated recurrence after ABR in CC athletes with a minimum follow-up period of 2 years postoperatively were included. We assessed the quality of the studies using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool, and we described the range of effects using synthesis without meta-analysis and described the certainty of the evidence using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations).

RESULTS

We identified 35 studies, which included 2,591 athletes. The studies had heterogeneous definitions of recurrence and classifications of sports. The recurrence rates after ABR varied significantly among studies between 3% and 51% (I2 = 84.9%, 35 studies and 2,591 participants). The range was at the higher end for participants younger than 20 years (range, 11%-51%; I2 = 81.7%) compared with older participants (range, 3%-30%; I2 = 54.7%). The recurrence rates also varied by recurrence definition (I2 = 83.3%) and within and across categories of CC sports (I2 = 83.8%). CC athletes had higher recurrence rates than did non-collision athletes (7%-29% vs 0%-14%; I2 = 29.2%; 12 studies with 612 participants). Overall, the risk of bias of all the included studies was determined to be moderate. The certainty of the evidence was low owing to study design (Level III-IV evidence), study limitations, and inconsistency.

CONCLUSIONS

There was high variability in the recurrence rates reported after ABR according to the different types of CC sports, ranging from 3% to 51%. Moreover, variations in recurrence among CC sports were observed, with ice hockey players being in the upper range but field hockey players being in the lower range. Finally, CC athletes showed higher recurrence rates when compared with non-collision athletes.

LEVEL OF EVIDENCE

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

Outcomes After Arthroscopic Revision Bankart Repair: An Updated Systematic Review of Recent Literature

PURPOSE

To provide an update of recent literature with a specialized focus on clinical outcomes following arthroscopic revision Bankart repair (ARBR) by performing a systematic review of all available literature published between 2013 and 2020.

METHODS

A literature search reporting clinical outcomes after ARBR was performed. Criteria for inclusion consisted of original studies; Level of Evidence of I-IV; studies focusing on clinical outcomes after ARBR published between January 1, 2013, and January 4, 2021; studies reporting recurrent dislocation or instability rate after ARBR; reoperation/revision following ARBR, return to sport rates following ARBR; and patient-reported outcomes. The primary outcomes of interest were failure defined as recurrent instability or dislocation, return to sport rates, and patient-reported outcomes at follow-up.

RESULTS

A large proportion of patients undergoing arthroscopic revision Bankart repair were male, ranging between 67.7% and 93.8%. Failure rate and return to sports rate ranged between 6.1% and 46.8% and 25.9% and 88.3%, respectively, when patients with significant or greater than 20% glenoid bone loss was excluded. Patient-reported outcome scores, which included American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale, saw significant improvement over mean follow-up of ranging 21.64 to 60 months.

CONCLUSIONS

Both the failure rate and RTS rates after ARBR had a wide range, given the heterogeneity of the studies included, which varied in patient selection criteria pertaining to patients with greater than 20% glenoid bone. Although there have been advancements in arthroscopic techniques and a trend favoring arthroscopic stabilization procedures, there is a lack of consensus in recent literature for careful patient selection criteria that would minimize failure rates and maximize RTS rates after ARBR.

LEVEL OF EVIDENCE

Level IV, a systematic review of Level III-IV studies.

On the Rise: The Increasing Frequency of Pediatric Shoulder Stabilization Surgery in Children and Adolescents

The management of shoulder instability in children and adolescents continues to evolve. The purpose of this study was to evaluate the epidemiology of shoulder stabilization procedures in a large, nationally representative pediatric population. The Pediatric Health Information System (PHIS) database was queried for patients 18 years and younger undergoing surgical shoulder stabilization between 2008 and 2017. Patients undergoing arthroscopic surgery were compared with patients undergoing complex (open or bony augment stabilization) procedures. Annual trends were calculated using linear regression. A total of 3925 procedures were performed, of which 92.9% were arthroscopic Bankart repairs. There was a significant increase in overall pediatric shoulder stabilizations and arthroscopic repairs between 2008 and 2017. Complex procedures were performed most often in the Northeast, but the annual frequency did not increase nationally. [Orthopedics. 202X;XX(X):xx-xx.].

Safety, Efficacy, and Cost-Effectiveness of Simultaneous Bilateral Arthroscopic Bankart Repair for Bilateral Shoulder Instability

Background:

Bilateral shoulder instability and Bankart lesions are not rare and frequently require surgical treatment. Bilateral instability may be treated with either a single-stage, simultaneous bilateral Bankart repair or 2-stage surgery.

Purpose/Hypothesis:

To compare simultaneous bilateral arthroscopic Bankart repair to 2-stage repair in terms of clinical outcomes and hospitalization costs. It was hypothesized that simultaneous repair would provide clinical outcomes similar to those of 2-stage Bankart repair while yielding lower hospitalization costs.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent simultaneous bilateral arthroscopic Bankart repair (group 1) were matched by age, sex, and injury type to control patients who had unilateral Bankart repair (group 2). All patients were operated on by the same surgeon in the same institution between 2007 and 2017 and had a minimum follow-up duration of 24 months. Patients with inflammatory arthritis, metabolic/malignant disease, previous shoulder surgery, a glenoid bone loss ≥25%, or off-track Hill-Sachs lesion were excluded. The 2 groups were compared in terms of pre- and postoperative Western Ontario Shoulder Instability Index (WOSI) scores, hospitalization costs, complications, and recurrent instability. The hospitalization cost of group 2 was multiplied by 2 to create a projection of the estimated cost of 2 sequential unilateral Bankart repairs.

Results:

The study population comprised 48 patients (38 men [79.17%] and 10 women [20.83%]; mean age, 25.5 years at surgery and 22.75 years at first dislocation). Group 1 included 32 shoulders in 16 patients, while group 2 consisted of 32 shoulders in 32 patients. The mean hospitalization cost (in 2020 US dollars) was $26,010 ± $1455 for group 1 and $33,591 ± $1574 for group 2 (P < .001). Both groups had improved WOSI scores after surgery and achieved similar scores at the latest follow-up. There was 1 redislocation in each group (3.13%). No surgery- or anesthesia-related/medical complications were recorded in either group.

Conclusion:

For bilateral shoulder instability, clinical outcomes of simultaneous bilateral arthroscopic Bankart repair were similar to those of 2-stage repair; however, lower hospitalization costs were seen after simultaneous bilateral repair compared with 2-stage surgery.

Trends in utilization and patient demographics for shoulder instability procedures from 2010 to 2019

BACKGROUND

Improved techniques and increased surgeon experience have optimized surgical care in patients with recurrent shoulder instability. Several techniques are used for surgical repair of shoulder instability, yet there are limited data on how utilization has changed over the past decade. The aim of this study was to assess trends in the utilization rate and patient demographic characteristics (age and sex) from 2010 to 2019 for 4 shoulder instability procedures: coracoid transfer/Latarjet procedure (LP), anterior bone block (ABB), open Bankart repair (OBR), and arthroscopic Bankart repair (ABR).

METHODS

We identified >87,000 patients using an all-payer claims database. The utilization rate was defined as the number of cases of a procedure divided by the total number of surgical cases for shoulder instability for any given year. Age was divided into 3 groups: <25 years, 25-35 years, and >35 years. Trends were reported in terms of the compounded annual growth rate (CAGR).

RESULTS

Although ABR was the most common shoulder instability procedure overall (91% utilization rate), the LP had the greatest increase in utilization from 2010 to 2019 (2.0% to 4.5%; CAGR, +9.8%). In comparison, the utilization of ABB procedures increased by 4.3% annually whereas that of OBR declined by 6.9% annually. The utilization of ABR showed minimal change. Notably, the LP was performed more frequently in younger patients over time. The percentage of patients aged < 25 years who underwent the LP increased from 30% to 41% from 2010 to 2019 (CAGR, +3.4%). There was a trend toward the performance of more LPs in men than in women (+1.2% vs. -3.5%, P < .05), although most cases (68%) were still performed in men.

CONCLUSION

ABR continues to account for most shoulder instability procedures. The LP had the greatest increase in the utilization rate from 2010 to 2019 and has now surpassed OBR in the utilization rate. ABB procedures are also being more frequently performed but only represent a minority of stabilization cases. During the course of the study period, a greater percentage of patients undergoing shoulder instability procedures were male individuals and were aged < 25 years.

Clinical outcomes of revision arthroscopic Bankart repair for anterior shoulder instability: a systematic review of studies

BACKGROUND

The purpose of this study was to review the literature to ascertain the functional outcomes, recurrence rates, and subsequent revision rates following revision arthroscopic Bankart repair.

METHODS

Two independent reviewers performed a literature search based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines using the Embase, MEDLINE, and Cochrane Library databases. Studies in which arthroscopic Bankart repair was performed as a revision procedure were included. The clinical outcomes extracted and analyzed were functional outcomes, return to play, and recurrent instability.

RESULTS

Fourteen studies with 433 patients met the inclusion criteria. The majority of patients were male patients (63.7%); the average age was 26.1 years (range, 14-58 years), and the mean follow-up period was 37.6 months (range, 10-144 months). The mean Rowe score was 84.2, and 79.7% of patients had good to excellent outcomes. The rate of return to play was 78.5%, with 47.5% of patients returning to their preinjury level of play across 10 studies. The rate of recurrent instability was reported in 12 studies, with 328 shoulders demonstrating 86 instability events (26.2%). The rate of recurrent instability due to dislocation was reported in 7 studies (n = 176), with 19 events (10.8%), whereas the rate of subluxation was reported in 4 studies (n = 76), with 6 events (7.9%).

CONCLUSIONS

Revision arthroscopic Bankart repair for anterior shoulder instability was shown to result in a high rate of recurrent shoulder instability. There was a relatively poor rate of return to sport among athletes, and only about half of the patients were able to return at or above their preoperative level of ability.

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

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

Current concepts in anterior glenohumeral instability: diagnosis and treatment

The glenohumeral joint is the most dislocated articulation, accounting for more than 50% of all joint dislocations. The reason behind shoulder instability should be investigated in detail for successful management, and the treatment plan should be individualized for all patients. Several classification systems have been proposed for glenohumeral instability. A physical exam is mandatory no matter what classification system is used. When treating patients with anterior shoulder instability, surgeons need to be aware of the critical size of the bone loss, which is commonly seen. The glenoid track concept was clinically adopted, and the measurement of the glenoid track for surgical decision-making is recommended. Detailed assessment of existing soft tissue injury to the labrum, capsule, glenohumeral ligaments, and rotator cuff is also mandatory as their presence influences the surgical outcome. Rehabilitation, arthroscopic repair techniques, open Bankart procedure, capsular plication, remplissage, Latarjet technique, iliac crest, and other bone grafts offer the surgeon different treatment options according to the type of patient and the lesions to be treated. Three-dimensional (3D) technologies can help to evaluate glenoid and humeral defects. Patient-specific guides are low-cost surgical instruments and can be used in shoulder instability surgery. 3D printing will undoubtedly become an essential tool to achieve the best results in glenohumeral instability surgery.

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.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

Level III, cross-sectional study.

Postoperative Evaluation of Patients Submitted to Arthroscopic Repair of Anterior Shoulder Instability

Objective  To clinically evaluate the results of patients undergoing arthroscopic surgical treatment of anterior shoulder instability.

Methods  A retrospective study of 94 patients. With a minimum follow-up of 24 months, we sought to correlate the characteristics of the patients and the surgery, such as age, gender, type of injury (traumatic or atraumatic) and the patient's position during surgery (lateral decubitus and beach chair) with the results obtained, the recurrence rate, the lateral rotation loss, the residual pain, and the functional scores of Carter-Rowe, University of California at Los Angeles (UCLA), and Constant-Murley.

Results  We observed a recurrent dislocation rate of 11.7%, lateral rotation loss in 37.23% of the patients, and some degree of residual pain in 51.6% of them. We obtained a mean Carter Rowe score of 85.37, representing 86% of good/excellent results. In the UCLA score, we obtained 88% of good/excellent results, similar to those obtained in the Constant-Murley score (86%).

Conclusion  The arthroscopic treatment of the anterior instability of the shoulder presents satisfactory results and low index of important complications, being the method of choice for most patients.

The 6-O'clock Anchor Increases Labral Repair Strength in a Biomechanical Shoulder Instability Model

PURPOSE

To characterize the additive effect of a 6-o'clock anchor in the stabilization of a Bankart lesion.

METHODS

Twelve cadaveric shoulders were tested on a 6-df robotic musculoskeletal simulator to measure the peak resistance force due to anterior displacement of 1 cm. The rotator cuff muscles were loaded dynamically. The test conditions consisted of the intact shoulder, Bankart lesion, Bankart repair (3-, 4-, and 5-o'clock anchors), and Bankart repair with the addition of a 6-o'clock anchor. A 13% anterior bone defect was then created, and all conditions were repeated. Repeated-measures analysis of variance was performed.

RESULTS

In the group with no bone loss, the addition of a 6-o'clock anchor yielded the highest peak resistance force (52.8 N; standard deviation [SD], 4.5 N), and its peak force was significantly greater than that of the standard Bankart repair by 15.8% (7.2 N, P = .003). With subcritical glenoid bone loss, the repair with the addition of a 6-o'clock anchor (peak force, 52.6 N; SD, 6.1 N; P = .006) had a significantly higher peak resistance force than the group with bone loss with a Bankart lesion (35.2 N; SD, 5.8 N). Although the 6-o'clock anchor did increase the strength of the standard repair by 6.7%, this was not statistically significant (P = .9) in the bone loss model.

CONCLUSIONS

The addition of a 6-o'clock suture anchor to a 3-anchor Bankart repair increases the peak resistance force to displacement in a biomechanical model, although this effect is lost with subcritical bone loss.

CLINICAL RELEVANCE

This study provides surgeons with essential biomechanical data to aid in the selection of the repair configuration.

Open Shoulder Stabilization for Instability: Anterior Labral Repair With Capsular Shift

Although anterior shoulder instability is most commonly treated with arthroscopic fixation, open labral repair with capsular shift may be best for select patients and in cases of revision stabilization without significant bone loss. The technique described in this article uses the deltopectoral interval; it involves careful dissection of the subscapularis from the anterior capsule, repair of the Bankart lesion, and a lateral and superior capsular shift using all-suture anchors in the humeral head. Advantages of this technique include meticulous control of anchor placement and the ability to provide additional stability via a lateral and superiorly directed capsular shift. This operation can be performed in a reliable, efficient, and reproducible manner.

Factors Influencing Surgeon's Choice of Procedure for Anterior Shoulder Instability: A Multicenter Prospective Cohort Study

PURPOSE

To investigate preoperative factors associated with selection of surgical treatment for anterior shoulder instability.

METHODS

Patient demographics, initial physical examinations, and patient-oriented outcome questionnaires were collected prospectively from 26 shoulder surgeons at 10 sites. Symptom duration, number of dislocations, sport, history of prior stabilization procedure, Hill-Sachs/glenoid bone loss, pain level, and failure of conservative treatment were recorded. Statistical analysis was performed with Fisher's exact test and logistic regression analysis.

RESULTS

A total of 564 patients who underwent surgical treatment for anterior shoulder instability from November 2012 to June 2017 were enrolled. Of these, 426 shoulders underwent arthroscopic stabilization alone, 38 underwent arthroscopic stabilization with remplissage, 28 underwent open Bankart repair, and 72 underwent a Latarjet procedure. Predictors for undergoing Latarjet (P < .003) were symptom duration (75% had symptoms for >1 year), number of dislocations (47% had >5 dislocations), revision surgery (69%), Hill-Sachs lesion size (45% had a lesion between 11% and 20% of the humeral head), and glenoid bone loss (75% of Latarjet patients had 11% to 30% loss). Predictors for undergoing open Bankart repair (P < .001) were number of dislocations (32% had >5 dislocations), revision surgeries (54%), and glenoid bone loss (11% of open Bankart patients had 11% to 20% loss). History of prior shoulder surgery was the only significant predictor of open versus arthroscopic Bankart procedure. Prediction models showed athletes involved in high-risk sports were 2.61 times more likely to have a Latarjet (P < .01).

CONCLUSIONS

Indications for the Latarjet were: humeral and glenoid bone loss, duration of symptoms, number of dislocations, and revision stabilizations. Athletes involved in high-risk sports were more likely to undergo the Latarjet procedure, even if other predictive factors were not present. The open Bankart procedure was the least common procedure performed, with a history of prior shoulder surgery being the only predictor for use when treating recurrent instability.

LEVEL OF EVIDENCE

Level II, prospective prognostic cohort investigation.

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.

Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis

OBJECTIVE

To review and compare treatments (1) after primary traumatic shoulder dislocation aimed at minimising the risk of chronic shoulder instability and (2) for chronic post-traumatic shoulder instability.

DESIGN

Intervention systematic review with random effects network meta-analysis and direct comparison meta-analyses.

DATA SOURCES

Electronic databases (Ovid MEDLINE, Cochrane Clinical Trials Register, Cochrane Database of Systematic Reviews, Embase, Scopus, CINAHL, Ovid MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, DARE, HTA, NHSEED, Web of Science) and reference lists were searched from inception to 15 January 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised trials comparing any interventions either after a first-time, traumatic shoulder dislocation or chronic post-traumatic shoulder instability, with a shoulder instability, function or quality of life outcome.

RESULTS

Twenty-two randomised controlled trials were included. There was moderate quality evidence suggesting that labrum repair reduced the risk of future shoulder dislocation (relative risk 0.15; 95% CI 0.03 to 0.8, p=0.026), and that with non-surgical management 47% of patients did not experience shoulder redislocation. Very low to low-quality evidence suggested no benefit of immobilisation in external rotation versus internal rotation. There was low-quality evidence that an open procedure was superior to arthroscopic surgery for preventing shoulder redislocations.

CONCLUSIONS

There was moderate-quality evidence that half of the patients managed with physiotherapy after a first-time traumatic shoulder dislocation did not experience recurrent shoulder dislocations. If chronic instability develops, surgery could be considered. There was no evidence regarding the effectiveness of surgical management for post-traumatic chronic shoulder instability.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Bone Loss and Glenohumeral Instability

Glenohumeral instability secondary to glenohumeral bone loss presents a complex problem to the treating surgeon because of the complex biomechanics of the glenohumeral joint and its reliance on numerous dynamic and static stabilizers. The role of glenoid bone loss, specifically inferior-anterior glenoid bone loss, has been well characterized in the setting of recurrent unidirectional instability with greatly improved clinical results when following an algorithmic reconstructive approach to the location and percentage of overall bone loss. Furthermore, as the role of bipolar bone loss in the setting of glenohumeral engagement becomes more apparent, surgeons can more effectively address those lesions contributing to the recurrent instability. As such, surgeons should carefully and critically asses patients with recurrent anterior instability to optimize patient clinical outcomes.

Results of Open Bankart Surgery for Recurrent Anterior Shoulder Dislocation with Glenoid Bone Defect and Concomitant Hill-Sachs Lesion

BACKGROUND

Open Bankart surgery is the main treatment procedure in patients with recurrent anterior shoulder dislocation, especially in cases with glenoid bone defect. The goal of this study was to determine the outcomes after open Bankart surgery in cases of recurrent anterior shoulder dislocation with glenoid bone defects and concomitant Hill-Sachs lesions.

METHODS

Between 2006 and 2010, 89 patients with recurrent anterior shoulder dislocation and concomitant glenoid bone defects (10-30%) and Hill-Sachs lesions undergoing open Bankart surgery were reviewed. The mean follow-up after surgery was 7 years (5.5-9.5 years). The recurrence rate as well as the degree of shoulder pain and daily activity level was determined subjectively based on the visual analogue scale (VAS) and activity daily living scale (ADLs). Shoulder range of motion (ROM) in abduction and external rotation was compared with contralateral side; and finally, the American shoulder and elbow score (ASES) and constant-Murley score (CMS) were calculated.

RESULTS

Over 7 years of follow-up, a total of 15 patients (16.8%) undergoing surgery were found to have instability (3 patients (3.3%) with dislocation and 12 patients with (13.4%) subluxation). Patients with postsurgical instability had significantly larger glenoid bone defects (P=0.0001) and Hill-Sachs lesions (P=0.019) compared to those without instability. The mean loss of forward flexion compared with the normal contralateral side was 4º while the mean loss of external rotation between both sides was 5º. At the final visit, the average VAS was 0.4 (out of 10); ADL was 28.97 (range: 25-30); ASES was 96.1(range: 78.3-100); and the mean CMS value was 93.9(range: 82-100).

CONCLUSION

Open Bankart surgery with anteroinferior capsular shift for recurrent anterior shoulder dislocation with up to 30% glenoid bone defect and Hill-Sachs lesion provided desirable results in terms of shoulder function and recurrence rate. Bankart surgery is a successful and practical option in these patients and can be considered as an alternative to other procedures.

Trends in Shoulder Stabilization Techniques Used in the United States Based on a Large Private-Payer Database

Background

Arthroscopic stabilization is the most broadly used surgical procedure in the United States for management of recurrent shoulder instability. Latarjet coracoid transfer has been considered a salvage surgical procedure for failed arthroscopic repairs or cases of significant glenoid bone loss; however, with recent literature suggesting reduced risk of recurrent instability with Latarjet, several surgeons have advocated its broader utilization as a primary operation for treatment of shoulder instability.

Purpose

To determine trends in shoulder stabilization techniques used in the United States.

Study Design

Cross-sectional study.

Methods

A retrospective analysis of a publicly available national insurance database was performed to identify shoulder stabilization procedures performed over 9 years (2007-2015). The following Current Procedural Terminology codes were searched: 29806 (arthroscopic stabilization), 23455 (open capsulolabral repair), 23466 (open capsular shift), 23462 (Latarjet coracoid transfer), and 23460 (open anterior capsulorrhaphy with other bone block augmentation). Outcomes of interest included (1) trends in the use of each technique throughout the study interval, (2) age and sex distributions of patients undergoing each technique, and (3) regional predilections for the use of each technique.

Results

Arthroscopic stabilization was the most broadly used shoulder stabilization procedure in the database (87%), followed by open Bankart (7%), Latarjet (3.2%), open capsular shift (2.6%), and alternative bone block procedure (0.8%). Throughout the study period, the incidence of arthroscopic stabilization and Latarjet increased (8% and 15% per year, respectively); the incidence of open capsular shift remained relatively constant; and the incidence of open Bankart decreased (9% per year). Arthroscopic stabilization, open Bankart, and Latarjet each had similar sex-based distributions (roughly 70% male), while open capsular shift and alternative bone block were relatively more common in females (54% and 50% male, respectively). The incidence of arthroscopic stabilization and Latarjet were greatest in the South and lowest in the Northeast.

Conclusion

Arthroscopic stabilization remains the most commonly utilized stabilization technique in the United States. The use of the Latarjet procedure is steadily increasing and now rivals open Bankart stabilization among the most commonly used open stabilization techniques.

Arthroscopic Bankart Repair for the Management of Anterior Shoulder Instability: Indications and Outcomes

PURPOSE OF REVIEW

Arthroscopic Bankart repair is commonly utilized for shoulder stabilization in patients with anterior shoulder instability with minimum glenoid bone loss. The purpose of this review is to provide the indications, surgical technique, complications, and recent outcomes in arthroscopic Bankart repair for shoulder instability.

RECENT FINDINGS

Improvements in arthroscopic techniques have led to better patient outcomes, as well as an improved understanding of the pathoanatomy of instability. More recent studies have shown that one of the potential failures of primary arthroscopic repair may be due to unaddressed bone loss. This underscores the importance of evaluating glenoid bone loss and proper patient selection for this procedure to ensure successful outcome. When indicated, arthroscopic stabilization is the treatment of choice for many surgeons due to its lower morbidity and low overall complication rate. Future work must focus on longer-term outcomes in patients undergoing arthroscopic Bankart repair, as well as the clinical outcomes of new fixation techniques, augmentation techniques, and the effect of glenoid bone loss in outcome.

Return to Sports After Shoulder Stabilization Surgery for Anterior Shoulder Instability

PURPOSE OF REVIEW

Young athletes continue to experience traumatic shoulder instability and are often plagued by recurrent instability, limiting their return to sport. The purpose of this paper was to review return to sport in athletes after shoulder stabilization surgery for anterior shoulder instability.

RECENT FINDINGS

Athletes managed nonoperatively demonstrate unacceptably high rates of recurrent instability and are less likely to successfully return to sport. Operative management includes capsuloligamentous repair (arthroscopic versus open) and bone augmentation techniques. While modern arthroscopic techniques have provided favorable outcomes, open techniques have demonstrated lower recurrence rates among young collision athletes. A subset of athletes continue to experience recurrent instability, leading to further investigation of concomitant pathologies, which may put patients at risk of failure following Bankart repair. Bony augmentation procedures remain favorable for patients with glenoid bone loss; however, what constitutes critical bone loss in the decision between anterior labral repair versus bone augmentation has recently been questioned. Operative management of anterior shoulder instability provides superior results, including lower recurrent instability and return to sport. Future research on patient-specific risk factors may aid surgical decision-making and optimization of outcomes.