Treatment Of Traumatic Anterior Instability Research Articles

The prevalence of shoulders with a large glenoid defect and small bone fragment increases after several instability events during conservative treatment for traumatic anterior instability

Unstable shoulders with a large glenoid defect and small bone fragment are at higher risk for postoperative recurrence after arthroscopic Bankart repair. The purpose of the present study was to clarify the changes in the prevalence of such shoulders during conservative treatment for traumatic anterior instability. We retrospectively investigated 114 shoulders that underwent conservative treatment and computed tomography (CT) examination at least twice after an instability event in the period from July 2004 to December 2021. We investigated the changes in glenoid rim morphology, glenoid defect size, and bone fragment size from the first to the final CT. At first CT, 51 shoulders showed no glenoid bone defect, 12 showed glenoid erosion, and 51 showed a glenoid bone fragment [33 small bone fragment (<7.5%) and 18 large bone fragment (≥7.5%); mean size: 4.9±4.2% (0-17.9%)]. Among patients with glenoid defect (fragment and erosion), the mean glenoid defect was 5.4±6.6% (0-26.6%); 49 were considered a small glenoid defect (<13.5%) and 14 were a large glenoid defect (≥13.5%). While all 14 shoulders with large glenoid defect had a bone fragment, small fragment was solely seen in 4 shoulders. At final CT, 23 of the 51 shoulders persisted without glenoid defect. The number of shoulders presenting glenoid erosion increased from 12 to 24, and the number of shoulders with bone fragment increased from 51 to 67 [36 small bone fragment and 31 large bone fragment; mean size: 5.1±4.9% (0-21.1%)]. The prevalence of shoulders with no or a small bone fragment did not increase from first CT (71.4%) to final CT (65.9%; P=.488), and the bone fragment size did not decrease (P=.753). The number of shoulders with glenoid defect increased from 63 to 91 and the mean glenoid defect significantly increased to 9.9±6.6% (0-28.4%) (P<.001). The number of shoulders with large glenoid defect increased from 14 to 42 (P<.001). Of these 42 shoulders, 19 had no or a small bone fragment. Accordingly, among a total of 114 shoulders, the increase from first to final CT in the prevalence of a large glenoid defect accompanied by no or a small bone fragment was significant [4shoulders (3.5%) vs. 19 shoulders (16.7%); P=.002]. The prevalence of shoulders with a large glenoid defect and small bone fragment increases significantly after several instability events.

Open Bankart Repair: Where do We Stand Now?

The operative treatment for recurrent traumatic anterior shoulder dislocation is classified as an anatomical or non-anatomical technique. The anatomical technique was first described for more than 80 years ago by Dr. Arthur. S. B. Bankart.The anatomic reconstructionThe non-anatomic reconstructionBankart repair the Bristow-Latarjet procedure,the Eden-Hybinette procedure,the Magnusson-Stack procedure,the Putti-Platt procedure,the Weber Osteotomy procedure. Up to date, Bankart repair still is the most common procedure performed to treat recurrent anterior dislocation of the shoulder joint with Bankart lesion, the anterior-inferior labral disruption, namely as the most common pathology observed in 85% of those patients.2 At the earlier year, many orthopedic surgeons favored the open Bankart procedure for its reliable long term follow up result. Hence, open Bankart has been historically considered the gold standard in the treatment of shoulder instability.Open Bankart repair was previously a standard care, resulting in recurrence rates below 10%.3 Advocates of open Bankart surgery argue that a more anatomic and secure repair is reliably accomplished. However, arthroscopic shoulder stabilization methods have also evolved significantly during the past 25 years. Initially, there was an early disappointment for the high failure rates for arthroscopic Bankart repair as great as 49% for its trans-glenoid suturing and 23% for its bio-absorbable tack fixation.4 However, suture anchor came or should I say “save the day” and reduce the failure rates to 8 – 11% combined with capsular plication.5 United States’s data showed that arthroscopic Bankart repairs are increasingly used, from 71.2% of all cases in 2004 to 89% in 2009.6 Given the ceiling effect of a surgical learning curve in the last decade, the recurrence and failures rate should have been substantially decreased. These numbers have led to the suggestion that, could it be that arthroscopic Bankart repair with suture anchors is our ”blue ribbon” in this “competition”? Should we say ”abandon ship” now to open Bankart repair?A recent meta-analysis of open versus arthroscopic shoulder stabilization comparing 2 recent decades (the past 20 years) demonstrated there was no significant difference in improvements achieved for clinical outcomes and external rotation deficits.7 The recurrence rate for open Bankart surgery remained resolutely consistent at 10.7% (at the past 20 years) and 10.6% (at the past 10 years). The glory of arthroscopic surgery that has been taught for generations in orthopedic surgery is the ability to recon the additional intra-articular pathology with lower surgical morbidity, improved cosmesis and decreased pain. However, the earlier one can be mostly encountered by the advanced imaging system used these days. Hence, I would like to say, open Bankart surgery is considered not a history lesson and may be worthy to revisit.References Bankart ASB. The pathology and treatment of recurrent dislocation of the shoulder joint. British Journal of Surgery 1938; 26: 7. DOI: 10.1002/bjs.18002610104.Rowe CR, Patel D and Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am 1978; 60: 1-16. 1978/01/01.Rowe CR, Zarins B and Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am 1984; 66: 159-168. 1984/02/01.Freedman KB, Smith AP, Romeo AA, et al. Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for Recurrent Anterior instability of the shoulder: a meta-analysis. Am J Sports Med 2004; 32: 1520-1527. 2004/08/18. DOI: 10.1177/0363546504265188.Brophy RH and Marx RG. The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Arthroscopy 2009; 25: 298-304. 2009/02/28. DOI: 10.1016/j.arthro.2008.12.007.Zhang AL, Montgomery SR, Ngo SS, et al. Arthroscopic versus open shoulder stabilization: current practice patterns in the United States. Arthroscopy 2014; 30: 436-443. 2014/02/25. DOI: 10.1016/j.arthro.2013.12.013.Hohmann E, Tetsworth K and Glatt V. Open versus arthroscopic surgical treatment for anterior shoulder dislocation: a comparative systematic review and meta-analysis over the past 20 years. J Shoulder Elbow Surg 2017; 26: 1873-1880. 2017/07/10. DOI: 10.1016/j.jse.2017.04.009.

Criteria for assessing the effectiveness of arthroscopic access in the treatment of traumatic anterior instability of the shoulder joint

For an objective evaluation of the effectiveness of surgical ap­proach, topographic anatomical criteria are known, which include: the axis of the operating performance, wound depth, angle of surgical performance and operating performance axis tilt, access zone. With the use of technology in arthroscopic treatment of anterior instability of the shoulder joint it was nec­essary to adapt the proposed concepts in open surgery. Objec­tive:to evaluate the performance criteria of arthroscopic ac­cess to treatment of traumatic anterior instability of the shoul­der joint. Methods: We applied Sozon-Yaroshevich method and criteria for evaluating the effectiveness of surgical approach adapted for endoscopy. Results: The authors have changed some concepts that are used for evaluation of the wound in the ab­dominal endoscopic surgery. In particular, the angle of the op­erating performance, the apex of which is the point of setting the endoscopic port and rays — the direction of the instrument determines the possibility of moving the wound instruments and achieve extreme points of accessibility zones. Important for ar­throscopic surgery is the concept of range of motion of the in­strument (extreme possible its position within the port), the ef­fective angle of operational steps (between the extreme positions of the tool by which the execution of the necessary manipula­tions) area accessibility (areas of the bottom of the wound, which can be opened for inspection and manipulation). The concept: an optimal angle of attack, formed a line slope edge instruments and glenoid border when convenient to carry out manipulations to prepare input channel and anchor in articular edge of the blade; the effective accessibility zone (bottom area of the wound where the manipulations performed without restrictions). This scheme calculation of surgical approach. Conclusions: Ar­throscopic method of operation has certain performance stan­dards. Clinical features of pathology determine the different ap­proaches to treatment and improving arthroscopic technique.

Diagnosis and Treatment of Traumatic Anterior Instability of the Shoulder

Traumatic anterior glenohumeral joint dislocation is the most common type of shoulder instability. Lesions that usually result are avulsion of the anterior capsule and glenoid labrum from the glenoid rim (Bankart lesion), compression fracture of the posterosuperior humeral head (Hill-Sachs lesion), and laxity of the joint capsule. Another common lesion is a lengthwise disruption of the rotator cuff at the interval between the subcapularis and supraspinatus tendons. The shoulder that dislocates repeatedly after trauma has an excellent success rate when treated by surgical repair. The aim of the Bankart procedure is to restore stability to the shoulder by repairing the traumatic lesion of the anterior glenoid rim without altering normal anatomy.