Changes of Bipolar Bone Defect Size After Arthroscopic Bankart Repair for Traumatic Anterior Shoulder Instability: Evaluation Using a Scoring System and Influence on Postoperative Recurrence

Arthroscopic Latarjet yields better union and prevention of instability compared to arthroscopic bony Bankart repair in shoulders with recurrent anterior instability: a systematic review

PURPOSE

To determine whether arthroscopic Latarjet procedure or arthroscopic bony Bankart repair provide better outcomes in terms of rates of recurrent instability, non-union and complications, as well as clinical scores and range of motion.

METHODS

An electronic literature search was performed using PubMed, Embase®, and Cochrane databases, applying the following keywords: "Arthroscopic bony Bankart" OR "Arthroscopic osseous Bankart" AND "Arthroscopic Latarjet" OR "Arthroscopic coracoid bone block".

RESULTS

The systematic search returned 1465 records, of which 29 were included (arthroscopic bony Bankart repair, n = 16; arthroscopic Latarjet, n = 13). 37 datasets were included for data extraction, on 1483 shoulders. Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair had significantly higher instability rates (0.14; CI 0.10-0.18; vs 0.04; CI 0.02-0.06), significantly lower union rates (0.63; CI 0.28-0.91 vs 0.98; CI 0.93-1.00), and significantly lower pain on VAS (0.42; CI 0.17-0.67 vs 1.17; CI 0.96-1.38). There were no significant differences in preoperative glenoid bone loss, follow-up, complication rate, ROWE score, ASES score, external rotation, and anterior forward elevation between arthroscopic Latarjet and arthroscopic bony Bankart repair.

CONCLUSION

Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair results in significantly (i) higher rates of recurrent instability (14% vs 4%), (ii) lower union rates (63% vs 98%), but (iii) slightly lower pain on VAS (0.45 vs 1.17). There were no differences in complication rates, clinical scores, or postoperative ranges of motion.

LEVEL OF EVIDENCE

IV.

Native Glenoid Depth and Hill-Sachs Lesion Morphology in Traumatic Anterior Shoulder Instability

BACKGROUND

Although Hill-Sachs lesions (HSLs) are assumed to be influenced by glenoid characteristics in the context of bipolar bone loss, little is known about how glenoid concavity influences HSL morphology.

PURPOSE

To investigate the relationship between the native glenoid depth and HSL morphological characteristics.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Computed tomography images of bilateral shoulders from 151 consecutive patients with traumatic unilateral anterior shoulder instability were retrospectively reviewed. Patients were categorized into flat (<1 mm), moderate (1-2 mm), and deep (>2 mm) groups based on the native glenoid depth measured from the contralateral unaffected shoulder. The HSL morphological characteristics included size (depth, width, length, and volume), location (medial, superior, and inferior extent), and orientation (rim and center angle). The glenoid characteristics included diameter, depth, version, and bone loss. The patient, glenoid, and HSL morphological characteristics were compared among the 3 depth groups. Subsequently, the independent predictors of some critical HSL morphological characteristics were determined using multivariate stepwise regression.

RESULTS

After exclusion of 55 patients, a total of 96 patients were enrolled and classified into the flat group (n = 31), moderate group (n = 35), and deep group (n = 30). Compared with those in the flat group, patients in the deep group were more likely to have dislocation (38.7% vs 93.3%; P = .009) at the primary instability and had a significantly larger number of dislocations (1.1 ± 1.0 vs 2.2 ± 1.8; P = .010); moreover, patients in the deep group had significantly deeper, wider, larger volume, more medialized HSLs and higher incidences of off-track HSLs (all P≤ .025). No significant differences were detected among the 3 groups in HSL length, vertical position, and orientation (all P≥ .064). After adjustment for various radiological and patient factors in the multivariate regression model, native glenoid depth remained the strongest independent predictor for HSL depth (β = 0.346; P < .001), width (β = 0.262; P = .009), volume (β = 0.331; P = .001), and medialization (β = -0.297; P = .003).

CONCLUSION

The current study sheds light on the association between native glenoid depth and the morphology of HSLs in traumatic anterior shoulder instability. Native glenoid depth was independently and positively associated with HSL depth, width, volume, and medialization. Patients with deeper native glenoids were more likely to have off-track HSLs and thus require more attention in the process of diagnosis and treatment.

Contribution of the Bony Bankart in Calculating Glenoid Bone Loss

Background

Determining the magnitude of glenoid bone loss in patients with anterior shoulder instability is an important step in guiding management. Most calculations to estimate the bone loss do not include the bony Bankart fragment. However, if it can be reduced and adequately fixed, the estimation of bone loss may be decreased.

Purpose

To derive a simple equation to calculate the surface area of the bony fragment in Bankart fractures.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 26 patients suspected of having clinically significant bone loss underwent computed tomography imaging preoperatively, and the percentage of glenoid bone loss (%BL) was approximated with imaging software using a freehand region of interest area measurement with and without the inclusion of the bony Bankart fragment. By assuming this bony fragment as a hemi-ellipse with height, H, and thickness, d, we represented the surface are of the bony piece (Abonefragment=πHd4), and subtracted it from the overall %BL. They compared this value with the one found using imaging software.

Results

Without the inclusion of the bony Bankart, the overall %BL by the standard true-fit circle measured using imaging software was 23.8% ± 9.7%. When including the bony Bankart, the glenoid %BL measured using imaging software was found to be 12.1% ± 8.5%. The %BL calculated by our equation with the bony Bankart included was 10% ± 11.1%. There was no statistically significant difference between the %BL values measured using the equation and the imaging software (P = .46).

Conclusion

Using a simple equation that approximates the bony Bankart fragment as a hemiellipse allowed for estimation of the glenoid bone loss, assuming that the fragment can be reduced and adequately fixed. This method may serve as a helpful tool in preoperative planning when there are considerations for incorporating the bony fragment in the repair.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.

Clinical Outcomes of Arthroscopic Bony Bankart Repair for Anterior Instability of the Shoulder: A Systematic Review

BACKGROUND

Individual studies reporting the clinical outcomes of arthroscopic bony Bankart repair for anterior shoulder instability have reported excellent results but have been limited by their small sample sizes. No systematic review of the literature has been performed examining the clinical outcomes of arthroscopic bony Bankart repair.

PURPOSE

To provide a systematic review of the literature to examine the functional outcomes, recurrence rate, and return to sports rate after arthroscopic bony Bankart repair for anterior instability of the shoulder.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was conducted using the Cochrane Database of Systematic Reviews, Ovid/Embase, PubMed, and Web of Science. Studies that examined clinical outcomes after arthroscopic bony Bankart repair for anterior shoulder instability were included. Data pertaining to study characteristics and design, patient demographic characteristics, and clinical results, including functional outcomes, recurrence rate, and return to sports, were collected. The results from the studies were pooled, and weighted means and overall rates were calculated.

RESULTS

In total, 21 studies with 769 patients were included for analysis. Most patients were male (91.7%), the mean age was 26.7 years (range, 12-71 years), and the mean follow-up was 42.7 months (range, 6-120 months). The most commonly reported functional outcome score was the Rowe score (12 studies), which improved on average from 41.9 preoperatively to 90.8 postoperatively. The rate of recurrent instability was reported by all 21 studies, and the overall recurrence rate was 11.9% (88/738). Return to sports after arthroscopic bony Bankart repair was reported by 11 studies, with a pooled return to sports rate of 91.0% (264/290).

CONCLUSION

Arthroscopic bony Bankart repair for anterior shoulder instability resulted in improvements in functional outcomes, a low rate of recurrent instability, and a high rate of return to sports. Although these findings are extremely promising, future prospective studies with larger sample sizes are needed to further evaluate the clinical outcomes of arthroscopic bony Bankart repair.

Arthroscopic Bankart Repair and Open Bristow Procedure in the Treatment of Anterior Shoulder Instability With Osseous Glenoid Lesions in Collision Athletes

Background:

Traumatic anterior shoulder instability in collision sports athletes often involves osseous glenoid lesions, which make surgical treatment challenging. High redislocation rates have been seen in collision sports athletes treated using arthroscopic Bankart repair.

Purpose:

To investigate the effectiveness of a combined arthroscopic Bankart repair and open Bristow procedure for the treatment of traumatic anterior shoulder instability in collision sports athletes, with a focus on osseous glenoid lesions.

Study Design:

Case series; Level of evidence, 4.

Methods:

We reviewed 149 shoulders in 141 competitive collision sports athletes (mean ± standard deviation age, 20.1 ± 4.1 years; 8 bilateral cases) who underwent a combined arthroscopic Bankart repair and open Bristow procedure with minimum 2 years of follow-up. Osseous Bankart lesions were arthroscopically reduced and fixed using a coracoid graft.

Results:

Clinical outcomes as indicated by mean Rowe score improved significantly from 50.0 preoperatively to 98.9 postoperatively (P < .001) at a median follow-up of 3.4 years (range, 2.5-7 years). There were 2 recurrent dislocations (1.3%), both of which had nonunion of the transferred coracoid. Osseous Bankart lesions were observed in 85 shoulders, and osseous glenoid lesions ≥10% of the diameter of the nonoperative side were found in 58 shoulders, including 24 off-track cases. Clinical outcomes were not significantly different between patients with a glenoid defect ≥10% and <10%. Nonunion of the transferred coracoid was observed in 16 shoulders (10.7%), which had inferior Rowe scores; however, we could not define any risk factors for nonunion, including patient characteristics or bone morphology. Postoperative computed tomography performed in 29 patients >1 year after surgery showed successful repair of the osseous glenoid lesions, with a restored glenoid articular surface in all cases. Significant pre- to postoperative increases were seen in glenoid diameter (mean, 13.1% [95% CI, 9.9%-16.3%]; P < .001) and area (mean, 10.6% [95% CI, 8.5%-12.7%]; P < .001).

Conclusion:

A combined arthroscopic Bankart repair and open Bristow procedure improved bone morphology and was a reliable surgical method for treating collision sports athletes with traumatic anterior shoulder instability involving osseous glenoid lesions.

Bipolar Bone Defects in Shoulders With Primary Instability: Dislocation Versus Subluxation

Background:

In shoulders with traumatic anterior instability, a bipolar bone defect has been recognized as an important indicator of the prognosis.

Purpose:

To investigate bipolar bone defects at primary instability and compare the difference between dislocation and subluxation.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

There were 156 shoulders (156 patients) including 91 shoulders with dislocation and 65 shoulders with subluxation. Glenoid defects and Hill-Sachs lesions were classified into 5 size categories on 3-dimensional computed tomography (CT) scans and were allocated scores ranging from 0 (no defect) to 4 points (very large defect). To assess the combined size of the glenoid defect and Hill-Sachs lesion, the scores for both lesions were summed (range, 0-8 points). Patients in the dislocation and subluxation groups were compared regarding the prevalence of a glenoid defect, a bone fragment of bony Bankart lesion, a Hill-Sachs lesion, a bipolar bone defect, and an off-track Hill-Sachs lesion. Then, the combined size of the bipolar bone defects was compared between the dislocation and subluxation groups and among patients stratified by age at the time of CT scanning (<20, 20-29, and ≥30 years).

Results:

Hill-Sachs lesions were observed more frequently in the dislocation group (75.8%) compared with the subluxation group (27.7%; P < .001), whereas the prevalence of glenoid defects was not significantly different between groups (36.3% vs 29.2%, respectively; P = .393). The combined defect size was significantly larger in the dislocation versus subluxation group (mean ± SD combined defect score, 2.1 ± 1.6 vs 0.8 ± 0.9 points, respectively; P < .001) due to a larger Hill-Sachs lesion at dislocation than subluxation (glenoid defect score, 0.5 ± 0.9 vs 0.3 ± 0.6 points [P = .112]; Hill-Sachs lesion score, 1.6 ± 1.2 vs 0.4 ± 0.7 points [P < .001]). Combined defect size was larger in older patients than younger patients in the setting of dislocation (combined defect score, <20 years, 1.6 ± 1.2 points; 20-29 years, 1.9 ± 1.5 points; ≥30 years, 3.4 ± 1.6 points; P < .001) but was not different in the setting of subluxation (0.8 ± 1.0, 0.7 ± 0.9, and 0.8 ± 0.8 points, respectively; P = .885). An off-track Hill-Sachs lesion was observed in 2 older patients with dislocation but was not observed in shoulders with subluxation.

Conclusion:

The bipolar bone defect was significantly more frequent, and the combined size was greater in shoulders with primary dislocation and in older patients (≥30 years).