Arthroscopic Bankart Repair Research Articles

Paper 11: Return to Sport Testing vs Time-Based Clearance in Posterior Shoulder Instability

Objectives:Recurrent pain, instability and loss of function is a challenging complication that can occur after arthroscopic treatment of posterior shoulder instability and SLAP tears in athletes. Many surgeons allow return to sport after a designated arbitrary postoperative time point. Recent evidence has demonstrated that a majority of athletes have residual strength and functional limitations at 6 months postoperatively – the time at which most time-based protocols allow full return to sport1. Recent data has also been presented that patients undergoing arthroscopic Bankart repair who are required to meet objective return to sport testing criteria have a 4x lower rate of recurrent anterior instability than those who return based on time elapsed since surgery2. Considering these findings, the purpose of this study is to investigate the use of a similar objective return to sport testing protocol on recurrence rates following arthroscopic surgery for posterior shoulder instability and SLAP tears. We hypothesized that patients who meet objective return to sport criteria would have a lower rate of reoperation and recurrence of symptoms compared to those who did not undergo the testing and were cleared to return based on time from surgery.Methods:Consecutive patients (Group 1) who underwent arthroscopic posterior shoulder stabilization surgery with or without SLAP repair by a single surgeon from 2016 to 2019, had a minimum of 1 year follow up, and completed functional and strength testing to evaluate readiness for return to sport were included in this retrospective case-controlled study. These patients were compared to a control group of historical consecutive cases (Group 2) from 2012-2016 who did not undergo return to sports testing and were cleared for sports after a minimum of 6 months following surgery. Failure was defined as recurrent symptoms of pain or instability requiring reoperation. Exclusion criteria were: patients undergoing isolated anterior stabilization procedures with or without concomitant SLAP tears, multidirectional instability, and open procedures. Chi-square, Fisher exact tests and two-tailed Students T-test were performed. Statistical significance was set at p<0.05.Results:There were 33 patients in Group 1 who underwent return to sport testing, and 90 patients in Group 2, the historical control. There were no differences between groups regarding sex (p=0.46), hand dominance (p=0.16), side affected (p= 0.69. The average age of Group 1 (20.8 +/- 4 yrs) was significantly younger than Group 2 (31.6 +/- 9.1 yrs, p< 0.00001). Patients who underwent return to sport criteria-based testing protocol had a rate of recurrent symptoms of pain or instability of 12.1% compared to 18.9% for those who did not (p= 0.43). Similarly, there were no reoperations for in Group 1, while three patients in group 2 (3.3%) underwent revision surgery for recurrent symptoms. This difference, however, did not reach statistical significance (p= 0.5633).Conclusions:In our cohort of young patients undergoing arthroscopic surgery for posterior shoulder instability, we detected no significant difference in reoperation rate and recurrence of symptoms between athletes who underwent objective return to sport testing and those who were released to sport on a time-based protocol. This may be related to an overall lower rate of reoperation in patients undergoing arthroscopic posterior stabilization or SLAP repairs in general compared to those undergoing arthroscopic anterior stabilization and differences in tolerance and presentation of recurrent posterior instability/SLAP tears versus anterior instability. It is possible that criteria-based return to sport testing prior to clearance to return to sport may be less critical for improving failure rates following arthroscopic posterior stabilization and SLAP repair than for anterior stabilization. Alternatively, given low reoperation rates overall, future studies investigating the role of return to sport testing after arthroscopic surgery for posterior shoulder instability and SLAP repairs may need to include more patients in order to detect differences related to the testing protocol. Objective functional testing may be a viable alternative to arbitrary, time-based criteria for returning to sport in patients who have undergone arthroscopic posterior shoulder stabilization and SLAP repairs.

Long-Term Results and Failure Analysis of the Open Latarjet Procedure and Arthroscopic Bankart Repair in Adolescents.

The purpose of this study was to analyze the long-term results of arthroscopic Bankart repair compared with an open Latarjet procedure in adolescents who are at high risk for recurrent anterior shoulder instability. We hypothesized that the long-term stability rate of an open Latarjet procedure would be superior to that of arthroscopic Bankart repair. Forty eligible patients (41 shoulders) with a mean age of 16.4 years (range, 13 to 18 years) underwent arthroscopic Bankart repair, and 37 patients (40 shoulders) with a mean age of 16.7 years (range, 14 to 18 years) underwent an open Latarjet procedure. Of these, 34 patients (35 shoulders) in the Bankart group and 30 patients (31 shoulders) in the Latarjet group with long-term follow-up were compared; the overall follow-up rate was 82%. Clinical and radiographic results were obtained after a mean follow-up of 12.2 years (range, 8 to 18 years). Treatment failure occurred in 20 shoulders (57%) in the Bankart repair group and in 2 shoulders (6%) in the open Latarjet procedure group (p < 0.001), representing a significantly higher revision rate for instability in the Bankart group (13) compared with the Latarjet group (1) (p < 0.001). In patients without recurrent shoulder instability (15 in the Bankart group and 29 in the Latarjet group), there was a significant improvement in the Constant score (p = 0.006 in the Bankart group and p < 0.001 in the Latarjet group) and Subjective Shoulder Value (p = 0.009 in the Bankart group and p < 0.001 in the Latarjet group), without any significant difference between the 2 groups. Younger age was the only variable significantly correlated with failure following a Bankart repair (p = 0.01). Adolescents are at a high risk for treatment failure after Bankart repair, and, therefore, the Latarjet procedure should be strongly considered as a primary procedure for recurrent anterior shoulder instability in this population. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

No Difference in Outcomes After Arthroscopic Bankart Repair With Remplissage or Arthroscopic Latarjet Procedure for Anterior Shoulder Instability

PurposeTo evaluate the outcomes of arthroscopic Bankart repair with remplissage (ABRR) compared with the arthroscopic Latarjet (AL) procedure for anterior shoulder instability in patients with a labral tear and a concomitant engaging Hill-Sachs lesion.MethodsA retrospective review of patients who underwent either ABRR or the AL procedure for a diagnosis of anterior shoulder instability with a concomitant engaging Hill-Sachs lesion between 2011 and 2019 was performed. Recurrent instability, the visual analog scale score, the Subjective Shoulder Value, the Western Ontario Shoulder Instability score, patient satisfaction, willingness to undergo surgery again, and return to work or sport were evaluated.ResultsOur study included 41 patients treated with ABRR and 26 treated with the AL procedure. At final follow-up, there was no difference between patients who underwent ABRR and those who underwent the AL procedure in the reported Western Ontario Shoulder Instability score (21.8% vs 28.2%, P = .33) or any of its components, the visual analog scale score (0.9 vs 1.4, P = .32), the Subjective Shoulder Value (78.4 vs 74.5, P = .6062), the rate of satisfaction (81.6% vs 85.6%, P = .54), or whether patients would undergo surgery again (81.6% vs 96.1%, P = .16). Overall, 5 patients in the ABRR group and 2 patients in the AL group had recurrent instability events (12.2% vs 7.8%, P = .70), with no significant difference in the rate of recurrent dislocation (12.2% vs 3.8%, P = .39).ConclusionsIn patients with anterior shoulder instability and a concomitant Hill-Sachs lesion, both ABRR and the AL procedure were shown to be reliable treatments, with a low rate of recurrent instability and excellent patient-reported outcomes in appropriately selected patients. However, our study could not determine whether there was critical glenoid bone loss in patients undergoing ABRR, and surgeons should still exercise caution in performing ABRR in patients with high-grade glenoid bone loss or in those with failed prior stabilizations.Level of EvidenceLevel III, retrospective cohort study.

Arthroscopic Bankart repair with additional footprint fixation using the double-row technique at the 4 o'clock position anatomically restored the capsulolabral complex and showed good clinical results.

To investigate the clinical outcome and magnetic resonance imaging (MRI) findings after arthroscopic Bankart repair with additional double anchor footprint fixation (DAFF) at the 4 o'clock position, where the native footprint is widest anatomically, for recurrent anterior shoulder instability. Forty-two patients (mean age 27.0years) with recurrent anterior shoulder instability and without severe glenoid bone defects underwent arthroscopic Bankart repair with additional DAFF at the 4 o'clock position. Using three standard portals, single-row repair was performed at the 2, 3, and 5 o'clock positions, and DAFF with the suture bridging technique was conducted at the 4 o'clock position. MRI was performed preoperatively and at 6months postoperatively. Patients with follow-up periods of ≥1year were included in the present study and clinically evaluated at the final follow-up. The morphology at the 2 and 4 o'clock positions on radial MRI slices was compared between the preoperative and 6-month postoperative scans, and the footprint of the repaired capsulolabral complex at 6months postoperatively was compared between the 2 and 4 o'clock positions. The average follow-up period was 19.5 ± 6.2months. The rates of dislocation recurrence and positive apprehension test results were 2.4 and 4.8%, respectively. External rotation was restricted by 3.5°. The University of California at Los Angeles and Rowe scores at the final follow-up were 34.5 ± 1.0 points and 97.2 ± 5.7 points, respectively, representing significant improvements over the preoperative scores (p < 0.01). Although the capsulolabral complex at 6months postoperatively was firmly repaired at both the 2 and 4 o'clock positions compared to its preoperative state, the footprint of the restored capsulolabral complex was wider at the 4 o'clock position than at the 2 o'clock position (p < 0.01). Additional DAFF at the 4 o'clock position improved the glenohumeral stability and function of the shoulder joint. This study suggests that this technique is a reliable and useful treatment for shoulder instability. IV.

The Fragility Index of Statistically Significant Findings From Randomized Controlled Trials Comparing the Management Strategies of Anterior Shoulder Instability

Background: Debate centering on the management of anterior shoulder instability (ASI) in recent years has led to many randomized controlled trials (RCTs) being published on the topic. The fragility index (FI) has subsequently emerged as a novel method of assessing significant findings reported in RCTs, particularly those with small sample sizes. Purpose: To evaluate the FI of statistically significant findings in RCTs that reported the outcomes of management strategies of patients with ASI. Study Design: Systematic review; Level of evidence, 1. Methods: Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent reviewers performed a systematic review of RCTs focusing on the outcomes of management strategies of patients with ASI. There were 3 main categories of RCTs included: (1) nonoperative management in internal rotation (IR) versus external rotation (ER), (2) nonoperative management versus a surgical intervention, and (3) surgical management with arthroscopic Bankart repair versus open Bankart repair. The Fisher exact test was utilized to calculate the FI for the reversal of statistical significance in all statistically significant dichotomous outcomes. Results: A total of 21 RCTs were included, including 1589 shoulders (mean age, 29.4 years) with a mean follow–up of 26.8 months. There were 10 RCTs (831 shoulders) that reported outcomes after the nonoperative management of ASI in IR versus ER, with a mean FI of 6.8. There were 5 RCTs (324 shoulders) that reported outcomes comparing the nonoperative and operative management of ASI, with a mean FI of 3.5. There were 6 RCTs (434 shoulders) that reported outcomes after the operative management of ASI with either arthroscopic Bankart repair or open Bankart repair, with a mean FI of 9.6. Conclusion: The overall FI of RCTs reporting the outcomes of management strategies for patients with ASI was high, suggesting a moderate fragility of statistically significant outcomes including recurrence, revision stabilization, and return to play.

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up

Background: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair. Purpose: To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed. Results: A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively (P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 (P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) (P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years (P = .311). Conclusion: Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

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

BackgroundThe effect of time interval between injury and surgery on outcomes of Bankart repair surgery has not been published previously. The purpose of this study was to assess the effect of surgical delay on functional outcomes after arthroscopic Bankart repair. MethodOne hundred and five athletes who underwent arthroscopic Bankart repair ± remplissage were enrolled in the study. Patients were divided into 2 groups depending upon the injury to surgery time- < 12 months (n = 19), and ≥12 months (n = 86). Depending upon the number of episodes of dislocation, patients were further categorized into 2 groups- <10 episodes (n = 66) and ≥10 episodes (n = 39). All patients were assessed post-operatively for functional outcomes (Modified Rowe's score, Constant Murley score) and return to sports at a minimum of 2 years of follow-up. ResultsThe mean injury to surgery time was 31.7 ± 23.1 months. The average number of episodes of dislocation before surgery were 10 (range 3–50). 49/105 (46.7%) patients returned to sports after a mean post-operative duration of 10.9 months. Athletes operated after a surgical delay of ≥12 months had inferior functional outcomes (Modified Rowe's score-89.5 ± 8.9 vs.77.4 ± 21.4; p = 0.02), lower rate of return to sports (14/19 vs. 35/86; p = 0.02) and higher mean time to return to sports (8.7 ± 1.9 vs. 11.5 ± 2.6; p < 0.05). Similarly, athletes who had ≥10 dislocations before surgery had inferior functional outcomes (Modified Rowe's score-84.5 ± 15.2 vs.72.9 ± 25.6; p = 0.004), lower rate of return to sports (37/66 vs. 12/39; p = 0.02) and higher mean time to return to sports (10.3 ± 2.4 vs. 12.6 ± 2.5; p < 0.05). ConclusionA delay in surgery (≥12 months) or dislocation episodes of ≥10 are associated with inferior functional outcomes, lower rate of return to sports and higher surgical failure rate. Level of evidenceLevel III; Prospective cohort study.

Remplissage Yields Similar 2-Year Outcomes, Fewer Complications, and Low Recurrence Compared to Latarjet Across a Wide Range of Preoperative Glenoid Bone Loss

The purpose of this study was to compare functional outcome, return to sport, satisfaction, postoperative recurrence, and complications in patients undergoing primary arthroscopic Bankart repair with remplissage (ABR) to primary Latarjet. A multicenter retrospective study was performed on patients undergoing primary ABR or open Latarjet between 2013 and 2019 who had a minimum 2-year follow-up. Baseline and two-year range of motion (ROM), patient-reported outcomes (PROs: Western Ontario Shoulder Instability Index [WOSI], Single Assessment Numeric Evaluation [SANE], and visual analog scale [VAS] for pain) recurrence, return to sport, satisfaction, and complications were reviewed. This study included 258 patients, including 70 ABRs and 188 Latarjet procedures. Baseline demographics, ROM, and PROs were similar. Mean preop glenoid bone loss (GBL) (12.3% ± 10.9% vs 7.6% ± 9%; P < .001) and off-track lesions (23% vs 13%; P= .046) were higher in the ABR group, while preoperative GBL range was similar (0-42% vs 0-47%). Changes in the VAS (1.9 vs 0.9; P= .019) and WOSI (1096 vs 805; P < .001) were improved in ABR. The percentage of patients who achieved a minimal clinically important difference was improved in WOSI for ABR and PASS for ABR in SANE, VAS, and WOSI scores. The ABR cohort reported worse changes in external rotation (ER) (-4° vs+19°; P < .001). Return to sport among overhead and contact athletes favored ABR (91.5% vs 72.7%; P= .007). Satisfaction and recurrent dislocation were similar. Surgical complications were observed in 0% of ABR cases, compared to 5.9% in the Latarjet group. Primary ABR resulted in 2-year functional outcomes that were as good or superior to primary Latarjet, with higher return to sport for overhead and contact activities, fewer complications, and comparably low recurrence rates, even despite greater bipolar bone loss in the ABR cohort. However, this comes at the expense of decreased external rotation, which may be considered in individual patients. III, retrospective comparative study.

Factors That Influence the Return to Sport After Arthroscopic Bankart Repair for Glenohumeral Instability.

Numerous studies have reported high rates of return to sports following arthroscopic Bankart repair (ABR) However, there is enormous controversy regarding the optimal management of these patients in the postoperative period. Controversy issues include rehabilitation, criteria for returning to sports, and the specific management of each athlete according to the sport they practice. Even though there are several rehabilitation protocols published in the literature, wide variability exists concerning the key elements of rehabilitation after an ABR. Regarding criteria for return to sports, there is a wide variation across the different published studies. The type of sports has been shown to affect an athlete’s decision to return to sports. Nevertheless, most research is evaluated by classifications that cluster different sports into categories that may have other influences in return to sports when analyzed separately. Finally, in addition to physical readiness, the athlete’s psychological state is crucial for returning to sports. However, the contribution of psychological readiness to an athlete’s return to sports after shoulder instability surgery remains uncertain and unexplored.

Is a glenoid defect of 13.5% critical in male competitive rugby and American football players undergoing arthroscopic bony Bankart repair?

To investigate bone union and postoperative recurrence after arthroscopic bony Bankart repair (ABBR) in male competitive rugby and American football players with a subcritical defect of at least 13.5%.

Arthroscopic Reduction and Internal Fixation of an Osseous Bankart Lesion.

The current surgical video article outlines a technique for an osseous Bankart repair in a patient with a displaced fracture as well as substantial pain and instability. First, the amount of bone loss is measured on 3-dimensionally reconstructed computed tomography (CT) imaging, with the humeral head digitally subtracted2. The procedure is then performed arthroscopically with the patient in the lateral decubitus position. A diagnostic evaluation, beginning with posterior and anterior portal placement in the rotator interval, is completed to assess any rotator cuff injury and the extent of labral tearing and osseous displacement. Next, the bone fragment is elevated into its anatomical position. This fragment is then reduced with use of a double-row suture technique, followed by concomitant capsulolabral repair. Nonoperative treatment with a sling can be utilized as long as post-reduction CT scans reveal anteroposterior centering of the humeral head on the glenoid3. Rehabilitation can include active-assisted and passive glenohumeral mobilization, as well as daily pendulum exercises and physiotherapy. Osseous Bankart repair has been shown to effectively improve patient-reported outcomes and normalize glenoid morphology1,3,4. Failure to recognize and appropriately treat an osseous Bankart fracture may lead to osseous erosion caused by repetitive episodes of subluxations or dislocations, along with substantial pain and weakness5. Indications for arthroscopic Bankart repair include young, active patients with a reducible fracture fragment, an anterior glenoid deficit of >10%, and a history of failed nonoperative treatment3-8. Clinical outcomes following the osseous Bankart repair procedure have been shown to be highly successful, with high rates of return to sport, minimal reduction in range of motion, and restoration of shoulder function and stability4. Additionally, long-term follow-up has shown successful osseous union and normalization of glenoid anatomy1. Apply tension to sutures with a suture retriever before the PushLock anchors (Arthrex) are placed during fracture reduction.Utilize a trans-subscapularis portal for anchor placement medial to the fracture on the glenoid neck.Perform adjustable tensioning during labral repair with knotless all-suture anchors.Utilize a lateral distraction device with the patient in the lateral decubitus position to completely visualize the anteroinferior glenoid.Chronic onset and late intervention may cause difficulties in the reduction of the bone fragment.Suture management may be difficult, particularly for surgeons at an early stage of the learning curve.A defect that is wide (from medial to lateral) may be difficult to maneuver around and reduce. GH = glenohumeralGHL = glenohumeral ligamentPts = patientsPMH = previous medical historyFE = forward elevationER = external rotationIR = internal rotationABD = abductionEXT = external rotationXR = radiographic imagingMRI = magnetic resonance imagingCT = computed tomographyROM = range of motionFU = follow-upRTS = return to sportsRTPP = return to previous level of play.

Concomitant Glenolabral Articular Disruption (GLAD) Lesion is Not Associated With Inferior Clinical Outcomes After Arthroscopic Bankart Repair for Shoulder Instability: A Retrospective Comparative Study

PurposeThe purpose of this study was to compare outcomes between anterior shoulder instability patients with and without glenolabral articular disruption (GLAD) lesions after undergoing arthroscopic Bankart repair and to evaluate potential risk factors for inferior outcomes and recurrent instability.MethodsProspectively collected data were retrospectively reviewed for patients who underwent arthroscopic Bankart repair with and without GLAD lesions at a minimum of 2 years follow-up. Consecutive patients were matched by age, sex, and number of anchors. Patient-reported outcomes (PROs) were evaluated before and after surgery, including American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, Quick Disabilities of the Arm, Shoulder and Hand, Short Form-12 score, and satisfaction. Recurrent dislocation, subjective instability, and reoperation were analyzed. Additionally, PROs were assessed on the basis of GLAD lesion characteristics.ResultsA total of 54 patients (27 GLAD, 27 control) with a mean age of 28.9 ± 11.6 years were analyzed at mean 4.5 ± 1.9 years (range, 2-9 years) follow-up. Thirty-eight (70.3%) of the participants were male. Patients in both groups experienced significant improvements in all PROs (P ≤ .006 for all measures) and reported high median satisfaction (scale 1-10: 10 vs 10, P = .290) at final follow-up. Two patients in the GLAD cohort and 1 in the control cohort underwent reoperation (P = .588). Four (14.8%) patients in each group reported recurrent dislocation (P = 1.0). Additionally, 2 (7.4%) GLAD patients and 1 (3.7%) control patient reported subjective shoulder instability after surgery (P = 1.0). No significant differences in PROs were observed based on anchor/labral advancement or treatment with microfracture, nor were significant correlations observed between GLAD lesion size and PROs (P > .05 for all).ConclusionArthroscopic Bankart repair in patients with GLAD lesions resulted in significantly improved outcomes with high satisfaction, which was no different when compared with those without GLAD lesions.Level of EvidenceLevel III, retrospective comparative study.

Arthroscopic Bony Bankart Repair Using Suture Suspension to Increase Bone Contact Area

Bony Bankart lesions are anteroinferior glenoid rim fractures associated with capsulolabral tears. Untreated bony Bankart lesion can cause recurrent dislocation. So, the large bony Bankart lesions should be treated by anatomical reduction and stabilization. This Technical Note describes an arthroscopic bony Bankart lesion repair using suture suspension to increase contact area to gain more contact area and tissue compression to maximize the stability of the repair.

Bone Fragment Resorption and Clinical Outcomes of Traumatic Bony Bankart Lesion Treated With Arthroscopic Repair Versus Open Latarjet

Background: Bony Bankart lesions can perpetuate chronic anterior glenohumeral instability. When surgical treatment is pursued, several factors need to be considered to obtain optimal outcomes. Purpose: To (1) quantitatively describe patterns of bone fragment resorption and associated risk factors for developing glenoid bone loss (GBL) and (2) to compare clinical and radiological results of attritional bone loss treated with either the arthroscopic Bankart or the open Latarjet procedure. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective analysis of prospectively collected data was conducted for patients who underwent arthroscopic stabilization (group A1, 10%-20% GBL; group A2, >20% GBL) or open Latarjet (group B, >10% GBL) for recurrent shoulder instability with bony Bankart lesion. Patient characteristics, number of dislocations, and Western Ontario Shoulder Instability Index (WOSI) scores were obtained. Pre- and postoperative computed tomography imaging was used to quantitatively describe patterns of bone fragment resorption. Results: A total of 120 consecutive patients (group A1, 40; group A2, 23; group B, 57) were included in the study, with a mean age of 25.6 years (range, 19-35 years). The average follow-up was 5.0 years for all groups (range, 4.83-5.16 years in group A1, 4.58-5.41 years in group A2, and 4.33-5.67 years in group B). The mean times between dislocation event and surgery were 12.8 months (range, 6-32 months) and 13.6 months (range, 6-38 months) for groups A and B, respectively. Redislocation rates were 7.5% in group A1 versus 13.0% in group A2, and only occurred in patients with ≥13.5% GBL. There were no redislocations for group B (0%). Patients had better WOSI scores in group B (234.1 ± 126.9) than in group A (576.1 ± 224.6) (P < .0001). In group A, smaller preoperative bone fragment size displayed a higher percentage of resorption after surgery (r = −0.64; P < .05). Conclusion: A significant inverse relationship exists between preoperative bone fragment size and percentage of postoperative resorption. Patients treated with arthroscopic bony Bankart repair who had final GBL ≥13.5% had worse outcomes. When planned GBL approaches 13.5% in high-demand patients, a smaller fragment size can result in worse clinical outcomes because of resorption. In these cases, choosing the open Latarjet procedure leads to better clinical results.

Long-term results of arthroscopic Bankart repair with remplissage

Objectives:Arthroscopic Bankart repair with Hill-Sachs remplissage (BHSR) is suggested to treat anterior shoulder instability when there is an engaging humeral lesion. The objective of this study was to report the long-term clinical and radiological results of this procedure.Methods:This is a retrospective monocentric study including patients who underwent surgery for anterior shoulder instability by BHSR, seen again within a minimum of 5 years. 70% of the 51 patients (mean age 26 years; 16 - 49; ± 8.453 years) practiced sports. The mean ISIS score was 3.306 (0 - 7; ± 1.798). At the last follow-up, active range of motion, Subjective Shoulder Value (SSV), and Walch-Duplay and Rowe scores were measured. A radiographic assessment enabled the evaluation of arthrosis according to Samilson’s classification.Results:At a mean clinical follow-up of 86.8 months (60.0 - 123.9 ± 17.0 months), 83% of the patients had resumed sports activities. The mean Rowe, Walch-Duplay and SSV scores were 88.8 points (51-100; ± 12.4), 82.6 points (50 - 100; ± 16.4) and 87.9% (50 - 100, ± 8.5), respectively. 8 patients (15.6%) had a recurrence of dislocation or incomplete dislocation. In univariate analysis, patients who were stable at the last follow-up had a significant mean decrease in external rotation in adduction of 7° (p = 0.02) and in abduction of 6° RE2 (p = 0.006), a shallower Hill-Sachs (18% vs 25% of the humeral head diameter; p = 0.04), and were older (27 vs 19 years, p = 0.04). Radiographically, 84% of the patients had no osteoarthritis progression, while 13% had grade I osteoarthritis progression.Conclusion:BHSR allows resumption of sports activity in the majority of cases, with minor limitation of external rotation. However, the high failure rate in more than 5 years suggests that this procedure should be proposed with caution in case of a deep Hill-Sachs in young subjects.

Surgical treatment of anterior shoulder instability with glenoid bone loss with the Latarjet procedure in active-duty military service members.

The arthroscopic Bankart repair in the setting of glenoid bone loss has high rates of failure. In patients with anterior glenoid bone loss, the Latarjet provides glenohumeral stability through restoration of the glenoid bone, the conjoint tendon acting as a sling on the subscapularis, and anterior capsulolabral repair. Active-duty military personnel are at high risk for glenohumeral instability and have been equated to the contact athlete; most are young, male, and engage in contact sports. The purpose of this study is to assess the return to full-duty rates in active-duty military personnel following the Latarjet for anterior glenohumeral instability with glenoid bone loss. A retrospective review of all glenohumeral instability procedures were reviewed at a tertiary training hospital from June 2014 to June 2019. The patient population consisted of active-duty military personnel with glenoid bone loss and anterior glenohumeral instability, who were treated with a Latarjet. The primary outcome was return to full-duty status. There were 50 patients identified for the study. Four patients were lost to follow-up, leaving 46 of 50 patients (92.0%) eligible for this study. The average age at the time of the index procedure was 23.1 years. The average percentage bone loss was 18.4%. Forty-one patients (89.1%) were able to return to full-duty status. Four patients (8.7%) sustained a recurrent dislocation following the Latarjet; all 4 dislocations occurred during a combat deployment. Four patients (8.7%) reported episodes of subluxation without dislocation. Forty-one patients (89.1%) reported that their shoulders felt stable, and we found an average return to full duty at 5.3 months CONCLUSION: In our active-duty military cohort, we found an 8.7% rate of recurrent instability after a Latarjet procedure, and 41 patients (89.1%) were able to return to full-duty status. In conclusion, the Latarjet procedure in the active-duty military population with anterior glenoid bone loss resulted in a high rate of return to duty, excellent functional outcomes, low rate of recurrent instability, and a low overall complication rate.

The Painful Anterior Apprehension Test - an Indication of Occult Shoulder Instability.

Introduction:To evaluate the clinical relevance of the painful anterior apprehension test in shoulder instability.Materials and methods:We performed a retrospective study of 155 patients that underwent arthroscopic anterior Bankart repair between 2014–2016. Exclusion criteria were previous ipsilateral shoulder surgery, bony Bankart lesions, glenohumeral osteoarthritis and concomitant surgery involving rotator cuff tears, biceps tendon pathology and superior labrum from anterior to posterior (SLAP) lesions. The study cohort was divided into three groups: apprehension test with apprehension only, apprehension test with pain only, and apprehension test with both apprehension and pain. Patient demographics, clinical characteristics, radiological imaging, arthroscopy findings and surgical outcomes (Constant, American Shoulder and Elbow Surgeons (ASES), SF-36 scores) were evaluated.Results:A total of 115 (74.2%) had apprehension only, 26 (16.8%) had pain only and 14 (9.0%) had pain and apprehension with the apprehension test. Univariate analysis showed significant differences between the groups in patients with traumatic shoulder dislocation (p=0.028), patients presenting with pain (p=0.014) and patients presenting with recurrent dislocations (p=0.046). Patients with a purely painful apprehension test were more likely to have a traumatic shoulder dislocation, more likely to present only with pain, and less likely to present with recurrent shoulder dislocations. Multivariate analysis showed that none of these factors alone were significant as single predictors for shoulder instability. All three groups were otherwise similar in patient profile, MRI and arthroscopic assessments, and clinical outcomes of surgery. Excellent clinical outcomes were achieved in all groups with no difference in pre-operative and post-operative scores across all groups at all time points.Conclusion:The painful apprehension test may suggest underlying shoulder instability.

Long-term outcomes of arthroscopic Bankart repair and Hill-Sachs remplissage for bipolar bone defects.

To evaluate long-term results after arthroscopic Bankart repair and Hill-Sachs remplissage (BHSR) in bipolar bone defects with less than 20% of glenoid bone loss (GBL) and to analyse risk factors for recurrent dislocation. From 2009-2012, 43 patients with recurrent anterior shoulder instability were treated with BHSR. Inclusion criteria were GBL < 20% and minimum of 4-yearfollow-up. There were 35 males and 8 females with a mean age of 29years (range 16-53). The mean ISIS score was 3.6 (range 2-6). Patients were evaluated for recurrence, range of motion and functional outcomes (Walch-Duplay and Rowe score). Post-operative MRI was performed at least 6months after surgery to evaluate infraspinatus capsulotenodesis healing. Glenoid track was assessed retrospectively from pre-operative computed tomography. Mean follow-up was 7.3years (range 4-11). At the last follow-up, good to excellent outcomes were reported in 86% of patients. Average post-operative Walch-Duplay was 87.9 (range 75-100) and ROWE 93.7 (range 70-100). Infraspinatus capsulotenodesis healing was achieved in 86%. The rate of recurrence and revision surgery was 9.3% and 13.9%, respectively. Recurrence was associated with higher ISIS score (p = 0.0191) and lower age at surgery (p = 0.0227). Four (9.3%) Hill-Sachs lesions were considered off-track. The presence of off-track Hill-Sachs was associated with higher risk of recurrence (p < 0.00001). Arthroscopic BHSR improves shoulder instability in the setting of bipolar bone defects with less than 20% of GBL. Patient-related factors and pre-operative glenoid track should be taken into consideration to reduce the risk of recurrence.

Combined Double-Pulley Remplissage and Bankart Repair

The use of arthroscopic Bankart repair to treat anterior shoulder instability has become increasingly widespread. However, high rates of recurrent instability within the presence of glenohumeral bony defects, specifically Hill-Sachs lesions, have well documented a key concern regarding the arthroscopic Bankart repair process. Our technique describes the pairing of a remplissage to fill the Hill-Sachs lesion with the Bankart repair, preventing loss in shoulder stiffness and stability. This technique involves a double-pulley-combined remplissage and Bankart repair to maintain a low-failure, minimally invasive procedure.

Arthroscopic Bankart and Remplissage for Anteroinferior Instability With Subcritical Bone Loss Has a Low Recurrence Rate

ObjectiveTo demonstrate whether arthroscopic remplissage can achieve good outcomes without significantly impairing shoulder function.MethodsConsecutive patients with recurrent anterior glenohumeral dislocation, glenoid bone loss <20%, and engaging Hill–Sachs lesion who were operated with arthroscopic Bankart repair and remplissage between 2013 and 2016 were identified. Patients were evaluated clinically for shoulder instability, range of motion, and scored as per Oxford Shoulder Instability Score and University of California at Los Angeles score. The data were analyzed with the paired t test and the Wilcoxon signed rank test, as applicable. For all analyses, statistical significance was set at P < .05.ResultsTwenty-four patients were included in the study. The average age of the patients was 30 years (range, 18-47 years), with 91.67% (n = 22) male patients and 8.33% (n = 2) female patients. The range of motion at follow-up was comparable with the normal side, with loss of external rotation of 3.33° (n = 24). Significant improvement was observed in the Oxford Shoulder Instability Score (21.95 vs 41.29, P < 0.001) and University of California at Los Angeles score (18.33 vs 30.29, P < .001). A failure rate of 4.17% (1 patient with a positive apprehension test) was seen.ConclusionsArthroscopic Bankart repair with the remplissage procedure helps to re-establish stability and achieve good shoulder outcomes for patients with recurrent anterior glenohumeral dislocation and an engaging Hill–Sachs lesion and without significant glenoid bone loss.Level of EvidenceLevel IV, therapeutic.