A prospective, randomized, clinical and radiographic study after arthroscopic Bankart reconstruction using 2 different types of absorbable tacks

Large Drill Holes Are Still Present in the Long Term After Arthroscopic Bankart Repair With Absorbable Tacks: An 18-Year Randomized Prospective Study

BACKGROUND

Studies have demonstrated the development of an osseous reaction at the drill sites of anchors after arthroscopic shoulder surgery.

PURPOSE

To investigate the drill-hole size at 18 years after arthroscopic Bankart repair using either fast polygluconate acid (PGA) or slow polylevolactic acid (PLLA) absorbable tacks and to compare the functional outcomes and development of osteoarthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

40 patients with unidirectional anterior shoulder instability, treated with arthroscopic Bankart repair, were randomized into the PGA group (n = 20) or the PLLA group (n = 20). Plain radiographs of both shoulders, as well as computed tomography (CT) images of the operated shoulder, were used to evaluate the drill-hole size, volume, and degenerative changes. Functional outcomes were assessed by use of the Rowe score, Constant score, and Western Ontario Shoulder Instability (WOSI) index.

RESULTS

Of the 40 patients, 32 patients returned for the follow-up (15 PGA and 17 PLLA). No significant differences were found in the population characteristics between the study groups. The mean follow-up time was 18 years for both groups. No significant differences were seen in range of motion, strength in abduction, or Constant, Rowe, and WOSI scores between the groups. Recurrence rate was 33% in the PGA group and 6% in the PLLA group during the follow-up period (P = .07). The drill-hole appearance on plain radiographs (invisible/hardly visible/visible/cystic) was 11/2/2/0 and 6/5/5/1 for the PGA and PLLA groups, respectively (P = .036). The mean ± SD drill-hole volume as estimated on CT images was 89 ± 94 and 184 ± 158 mm³ in the PGA and PLLA groups, respectively (P = .051). Degenerative changes (normal/minor/moderate/severe) on plain radiographs were 7/4/4/0 and 3/8/5/1 for the PGA and PLLA groups, respectively (P = .21), and on CT images were 5/7/3/0 and 2/6/6/3 for the PGA and PLLA groups, respectively (P = .030).

CONCLUSION

This long-term follow-up study demonstrated that the PLLA group had significantly more visible drill holes than the PGA group on plain radiographs. However, this difference was not evident on CT imaging, with both groups having several visible cystic drill holes and a substantial drill-hole volume defect. No significant differences were found between the study groups in terms of clinical outcomes.

Anchor placement to glenoid rim during Bankart repair recreates contact area of anterior capsulolabral complex on glenoid better than onto articular surface

PURPOSE

This study aimed to compare the contact areas of Bankart repair with suture anchors placed on the articular surface of the glenoid versus at the rim of the glenoid because it is unclear which technique most effectively restores the footprint after Bankart repair.

METHODS

Ten fresh frozen cadaveric shoulders (mean age 70.7 years) were dissected. The attachment site of the capsulolabral complex from the 1 o' clock position to the 6 o'clock position was marked with ink, and the contact area of the anterior-inferior capsulolabral complex on the glenoid neck was measured using imageJ. Bankart lesions were created, and two types of Bankart repair were performed on each specimen. The suture anchors were inserted at the glenoid rim (Rim group) and onto the glenoid articular surface 2 mm from the rim (Surface group). Using pressure-sensitive films, we examined the interface contact area.

RESULTS

The Rim group recreated 64.9% of the native surface area, while the Surface group recreated 47.3% of the area. The Rim group recreated significantly greater contact area compared to the Surface group (P = 0.0008).

CONCLUSION

The anchor placement to the glenoid rim recreates the footprint of the capsulolabral complex on the anterior inferior glenoid better than the anchor placement onto the articular surface.

Osteointegration of a Biocomposite Suture Anchor After Arthroscopic Shoulder Labral Repair

PURPOSE

To evaluate osteoconductivity of a poly-L-lactide co-glycolide (PLG)-calcium sulfate (CS)-β-tricalcium phosphate (β-TCP) biocomposite suture anchor after arthroscopic shoulder labral repair.

METHODS

The subjects of this study were patients who participated in a clinical trial for acquisition of marketing approval of a PLG-CS-β-TCP biocomposite anchor in Japan. They underwent arthroscopic labral repair using the anchor, and computed tomographic (CT) images of the glenoid were obtained 2 years after surgery. Osteoconductivity at the anchor sites was evaluated with the CT images using the established ossification quality score. Shoulder function scores including the Rowe score and Japanese Shoulder Society shoulder instability score were also assessed 2 years after surgery.

RESULTS

CT images and functional scores were obtained from 37 patients, comprising 29 men and 8 women with a mean age of 29 years (range, 25-33 years) at surgery. A total of 148 anchors were implanted in the 37 shoulders. Osteoconductivity was seen in 133 of 148 anchor sites (90.0%) 2 years after implantation. No significant differences in osteoconductivity were found by anchor diameter or position. The Rowe score significantly improved from 39.9 points (95% confidence interval [CI], 33.8-45.9 points) preoperatively to 96.6 points (95% CI, 95.1-98.1 points) at 2 years postoperatively (P < .001). The Japanese Shoulder Society shoulder instability score also significantly improved, from 63.1 points (95% CI, 58.4-67.7 points) preoperatively to 96.3 points (95% CI, 94.7-97.8 points) at 2 years postoperatively (P < .001).

CONCLUSIONS

Biocomposite suture anchors made of PLG, CS, and β-TCP exhibited some osteoconductivity 2 years after arthroscopic labral repair, as well as good clinical outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

It's Not All About Redislocation: A Systematic Review of Complications After Anterior Shoulder Stabilization Surgery

BACKGROUND

The surgical treatment of recurrent shoulder instability has evolved in recent years to include a variety of soft tissue and bone block procedures, undertaken with either an open or arthroscopic approach. Although the utilization of such techniques has rapidly expanded, the associated risk of complications remains poorly defined. This information is vital for clinical decision making and patient counseling.

PURPOSE

To quantify the complication rate associated with all types of surgery for anterior glenohumeral joint dislocation.

STUDY DESIGN

Systematic review.

METHODS

A systematic search was undertaken of studies reporting complications from anterior shoulder stabilization surgery. Inclusion criteria were studies published in English between 2000 and 2017 with a minimum 2-year follow-up. Methodological quality of the included studies was assessed with the Methodological Index for Non-Randomized Studies criteria. Complication rates for all undesirable events contributing to the patient outcome were extracted and cumulative rates calculated.

RESULTS

Out of 1942 references, 56 studies were included, totaling 4362 procedures among 4336 patients. Arthroscopic soft tissue repair had a complication rate of 1.6% (n = 2805). When repair was combined with arthroscopic remplissage, the rate was 0.5% (n = 219). Open soft tissue repair had a complication rate of 6.2% (n = 219) and open labral repair with remplissage, a rate of 2.3% (n = 79). An open bone block procedure had a complication rate of 7.2% (n = 573) and an arthroscopic bone block procedure, a rate of 13.6% (n = 163).

CONCLUSION

This large systematic review demonstrates the overall complication rates (not purely recurrence rates) in modern shoulder stabilization surgery. With the growing interest in bone block stabilization procedures, including those performed arthroscopically, surgeons should be aware of the 10-fold increase in complications for these procedures over soft tissue arthroscopic surgery and counsel their patients accordingly.

Metallic versus biodegradable suture anchors for rotator cuff repair: a case control study

BACKGROUNDS

Repair of full-thickness rotator cuff (RC) tears is routinely performed using suture anchors, which produce secure and effective soft tissue fixation to bone. The aim of this prospective study is to compare the long-term outcomes of single row arthroscopic rotator cuff repair (RCR) performed using metal or biodegradable suture anchors. The null hypothesis is that there is no difference in shoulder function using metal or biodegradable suture anchors as evaluated by UCLA shoulder score, Wolfgang criteria, and Oxford shoulder score.

METHODS

Arthroscopic RCR was performed in 110 patients included in this case control study. They were divided into 2 groups of 51 and 59 patients respectively. Metal suture anchors were used in group 1, and biodegradable suture anchors in group 2. Results were obtained at a mean follow up of 4.05 + 2 years. Clinical outcomes and functional outcomes were evaluated.

RESULTS

The mean modified UCLA shoulder score was 26.9 + 7.1 in group 1, and 27.7 + 6.5 in group 2 (P = 0.5); the mean Wolfgang score was 13.3 + 3.3 in group 1, and 14 + 2.6 in group 2 (P = 0.3); the mean OSS was 23.7 + 11.4 in group 1, and 20.7 + 9.2 points in group 2 (P = 0.1). The mean active anterior elevation was 163.5° + 28.2° in group 1 and 163.6° + 26.9 in group 2 (P = 0.9); the mean active external rotation was 46° + 19.7° in group 1 and 44.6° + 16.3° in group 2 (P = 0.7). The mean strength in anterior elevation was 4.8.02 + 23.52 N in group 1, and 43.12 + 17.64 N in group 2 (P = 0.2); the mean strength in external rotation was 48.02 + 22.54 N in group 1 and 46.06 + 17.64 N in group 2 (P = 0.6); the mean strength in internal rotation was 67.62 + 29.4 N in group 1, and 68.6 + 25.48 N in group 2 (P = 0.9).

CONCLUSIONS

There are no statistically significant differences at a mean follow-up of 4.05 + 2 years in clinical and functional outcomes of single row arthroscopic RCR using metallic or biodegradable suture anchors for RC < 5 cm.

Comparison of Tunnel Enlargement and Clinical Outcome Between Bioabsorbable Interference Screws and Cortical Button-Post Fixation in Arthroscopic Double-Bundle Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Study With a Minimum Follow-Up of 2 Years

PURPOSE

To investigate the tunnel enlargement rate and clinical function by comparing double-bundle anterior cruciate ligament reconstruction (ACLR) using different fixation devices.

METHODS

Patients receiving primary arthroscopic double-bundle ACLR were screened and divided into 2 groups on the basis of the method of graft fixation: bioabsorbable interference screw (BS) group and cortical button (CB) group. Bone tunnel size was assessed digitally using magnetic resonance imaging, which was performed a minimum of 2 years postoperatively. Clinical evaluations were performed using the Knee Injury and Osteoarthritis Outcome Score, International Knee Documentation Committee score, and KT-1000 arthrometer 2 years postoperatively.

RESULTS

Sixty patients receiving primary arthroscopic double-bundle ACLR were included. Overall, the BS group showed greater tunnel enlargement than the CB group, as well as a significantly increased rate of tunnel communication (P = .029). The average anteromedial tunnel enlargement rates for the BS and CB groups were 50% and 28%, respectively. The enlargement rate of the posterolateral (PL) femoral tunnel was similar in both groups. In the PL tibial tunnel, the CB group showed a significant increase in enlargement compared with the BS group (64% vs 45%, P = .0001). Both groups showed functional improvement in the Knee Injury and Osteoarthritis Outcome Score and International Knee Documentation Committee score. No significant difference in postoperative functional outcomes was found between the 2 groups.

CONCLUSIONS

The BS group showed significantly greater tunnel enlargement in anteromedial tunnels and an increased tunnel communication rate compared with the CB group. On the other hand, the CB group showed greater tunnel enlargement in tibial PL tunnels. Tunnel communication was observed mostly on the tibial side in the BS patients. Equivalent clinical function outcomes were noted at 2 years after surgery in both groups of patients.

LEVEL OF EVIDENCE

Level II, randomized controlled clinical trial.

Surgical treatment outcomes after primary vs recurrent anterior shoulder instability

INTRODUCTION

The aim of this study is to compare the outcomes of surgical management after primary anterior shoulder dislocation to the outcomes of patients who have surgical stabilization after recurrent anterior shoulder instability.

METHODS

A Medline (PubMed) search was performed in November of 2016 using the following key terms: shoulder, labrum, Bankart, instability, repair, outcome, recurrent. In May 2017 a Cochrane search was performed using similar key terms to ensure we included all studies. Only level I and II studies were included.

RESULTS

There were three studies that compared primary repair to delayed repair. In all three studies, the rate of recurrence was higher in group R than group S. When pooled, there was not a statistically significant difference between these groups, but there was a slightly higher odds of recurrence in group R (pooled OR 2.08, CI 0.69-6.26, p = 0.19). No significant differences were appreciated in functional outcomes or complications in these two groups.

CONCLUSION

Further level I and level II studies to compare surgical treatment after first time and recurrent instability are needed. This study failed to find a statistically significant difference in recurrence rates in patients who had stabilization acutely after a single episode compared to patients with recurrent instability events, although results suggest there may be a small benefit in primary stabilization.

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.

An assessment of quality of randomized controlled trials in shoulder instability surgery using a modification of the clear CLEAR-NPT score

BACKGROUND

The present study aimed to evaluate the methodological quality and determine the quality of reporting of randomized controlled trials (RCTs) that assess surgical treatment for shoulder instability.

METHODS

A Cochrane, Pubmed, EMBASE and Trip database search was performed, including the relevant literature, regarding RCTs that report on shoulder instability published between January 1994 and January 2017. Methodological quality was assessed with a modification of the Checklist to Evaluate A Report of a Nonpharmacologic Trial (CLEAR-NPT). Points were assigned based on 18 items regarding patient characteristics, randomization, care provider characteristics, surgical details and blinding, with a total score ranging from 0 points to 18 points. Missing items were verified with the corresponding authors of the studies. Quality of reporting corresponds to the total scores including the items that were additionally provided by the authors.

RESULTS

We included 22 studies. Of these, nine corresponding authors provided additional information. The average methodological quality was 16.9 points (11 studies) and the average quality of reporting was 9.5 points (22 studies). Items scoring worst included information regarding the surgeon's experience, the patients' level of activity, comorbidities, analyzing according to 'intention-to-treat' principles, and blinding of care providers, participants and assessors.

CONCLUSIONS

RCTs reporting on shoulder instability surgery are well performed but poorly reported.

Traumatic anterior instability of the shoulder

The shoulder is the most unstable joint in the human body. Traumatic anterior instability of the shoulder is a common condition, which, especially in young patients, is associated with high recurrence rates. The effectiveness of non-surgical treatments when compared to surgical ones is still controversial. The purpose of this study was to review the literature for current concepts and updates regarding the treatment of this condition.

Long-term outcomes of the Bankart and Latarjet repairs: a systematic review

The most common surgical techniques for the treatment of recurrent anterior shoulder instability include the arthroscopic Bankart repair, the open Bankart repair and the open Latarjet procedure. The purpose of this study was to evaluate and compare the long-term outcomes following these procedures. A systematic review of modern procedures with a minimum follow-up of 5 years was completed. The objective outcome measures evaluated were post-operative dislocation and instability rate, the Rowe score, radiographic arthritis and complications. Twenty-eight studies with a total of 1652 repairs were analyzed. The estimated re-dislocation rate was 15.1% following arthroscopic Bankart repair, 7.7% following open Bankart repair and 2.7% following Latarjet repair, with the comparison between arthroscopic Bankart and open Latarjet reaching statistical significance (p<0.001). The rates of subjective instability and radiographic arthritis were consistently high across groups, with no statistical difference between groups. Estimated complication rates were statistically higher in the open Latarjet repair (9.4%) than in the arthroscopic Bankart (0%; p=0.002). The open Latarjet procedure yields the most reliable method of stabilization but the highest complication rate. There are uniformly high rates of post-operative subjective instability symptoms and radiographic arthritis at 5 years regardless of procedure choice.

Evaluation of postoperative results from videoarthroscopic treatment for recurrent shoulder dislocation using metal anchors

OBJECTIVE

To clinically and radiologically evaluate the results from videoarthroscopic treatment using metal anchors in patients with recurrent shoulder dislocation and its complications.

METHODS

This was a retrospective study on 47 patients (47 shoulders) operated by the shoulder group of the orthopedic hospital between February 2010 and February 2012. A questionnaire, interview and physical and radiographic examinations were used, with the classification of Samilson and Pietro. The mean postoperative follow-up was 33 months (range 12-47 months). The statistical analysis consisted of using Fisher's exact test through the IBM SPSS 22 statistical software. The significance level used was 5%.

RESULTS

Recurrence was observed in nine cases. The patients were, on average, 26.5 years old at the first episode, and 19.1% were aged 20 years or under. Among these, 55.6% presented recurrence. In relation to age at the time of the surgical procedure, the average age was 27 years, and 12.8% were aged 20 years or under. Nineteen patients presented prominent anchors and, of these, 21% manifested arthrosis.

CONCLUSION

There was a statistically identified correlation between the recurrence rate and age less than or equal to 20 years at the times of first dislocation and the surgical procedure. Further studies should be conducted in order to compare the use of absorbable anchors, which despite higher cost, may provide lower risk of developing glenohumeral arthrosis in some cases.

Do arthroscopic and open stabilization techniques restore equivalent stability to the shoulder in the setting of anterior glenohumeral instability? a systematic review of overlapping meta-analyses

PURPOSE

Shoulder instability frequently recurs in young patients without operative treatment. Both open and arthroscopic approaches to shoulder stabilization with labral repair and capsulorrhaphy have been described and are routinely used. Multiple trials have been conducted to compare these approaches, with multiple meta-analyses performed to synthesize these trials; however, the results remain controversial. The purpose of this study was to critically evaluate the current meta-analyses to identify the current state of the art.

METHODS

In this study we evaluate available scientific support for the ability of both arthroscopic and open soft-tissue stabilization techniques to restore stability of the shoulder by performing a systematic review of the literature for previous meta-analyses. Data were extracted for rates of recurrence and patient outcomes. Study quality was measured with the Oxman-Guyatt and QUOROM (Quality of Reporting of Meta-analyses) systems. The Jadad algorithm was applied independently by 4 authors to determine which meta-analysis provided the highest level of available evidence.

RESULTS

After application of the inclusion and exclusion criteria, 8 meta-analyses were included. Both studies published prior to 2007 concluded that open stabilization provided lower recurrence rates than arthroscopic stabilization, the 3 studies published in 2007 are discordant, and all 3 studies published after 2008 concluded that open and arthroscopic stabilization provided equivalent results. Two meta-analyses had low Oxman-Guyatt scores (<3) signifying major flaws. Four authors independently selected the same meta-analysis as providing the highest quality of evidence using the Jadad algorithm, and this meta-analysis found no difference in recurrence rates between open and arthroscopic stabilization.

CONCLUSIONS

This systematic review of overlapping meta-analyses comparing arthroscopic and open shoulder stabilization suggests that according to current best available evidence, there are no significant differences in failure rates.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Outcomes of arthroscopic anterior shoulder instability in the beach chair versus lateral decubitus position: a systematic review and meta-regression analysis

PURPOSE

This study aimed to systematically review the clinical outcomes and recurrence rates after arthroscopic anterior shoulder stabilization in the beach chair (BC) and lateral decubitus (LD) positions.

METHODS

The authors performed a systematic review of multiple medical databases using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All English-language literature from 1990 to 2013 reporting clinical outcomes after arthroscopic anterior shoulder stabilization with suture anchors or tacks with a minimum 2-year follow-up period were reviewed by 2 independent reviewers. Data on recurrent instability rate, return to activity/sport, range of motion, and subjective outcome measures were collected. Study methodological quality was evaluated with the Modified Coleman Methodology Score (MCMS) and the Quality Appraisal Tool (QAT). To quantify the structured review of observational data, meta-analytic statistical methods were used.

RESULTS

Sixty-four studies (38 BC position, 26 LD position) met inclusion criteria. A total of 3,668 shoulders were included, with 2,211 of patients in the BC position (average age, 26.7 ± 3.8 years; 84.5% male sex) and 1,457 patients in the LD position (average age, 26.0 ± 3.0 years; 82.7% male sex). The average follow-up was 49.8 ± 29.5 months in the BC group compared with 38.7 ± 23.3 months in the LD group. Average overall recurrent instability rates were 14.65 ± 8.4% in the BC group (range, 0% to 38%) compared with 8.5% ± 7.1% in the LD group (range, 0% to 30%; P = .002). The average postoperative loss in external rotation motion (in abduction) was reported in 19 studies in the BC group and in13 studies in the LD group, with an average loss of 2.4° ± 1.0° and 3.6° ± 2.6° in each group, respectively (P > .05).

CONCLUSIONS

Excellent clinical outcomes with low recurrence rates can be obtained after arthroscopic anterior shoulder stabilization in either the BC or the LD position; however, lower recurrence rates are noted in the LD position. Additional long-term randomized clinical trials comparing these positions are needed to better understand the potential advantages and disadvantages of each position.

LEVEL OF EVIDENCE

Level IV, systematic review of studies with Level I through Level IV evidence.

Does the "bumper" created during Bankart repair contribute to shoulder stability?

BACKGROUND

The aim of this study was to determine the optimal repair configuration for anterior shoulder instability after a labral tear.

MATERIALS AND METHODS

Nine fresh, frozen shoulders were used. With a 50-N axial force, the humeral head was translated anteriorly, and the translational force was measured. The measurement was performed with the capsule intact, after creating a Bankart lesion, and after the Bankart repair at 5 different positions: glenoid rim, glenoid surface-2 mm (on the glenoid surface 2 mm from the glenoid rim), glenoid surface-5 mm, scapular neck-2 mm (on the scapular neck 2 mm from the glenoid rim), and scapular neck-5 mm. Glenoid rim fixation was done with and without a "bumper." The "bumper" was created by plicating the capsule to form a thickened mass of tissue.

RESULTS

The translational force was restored to the intact level after the glenoid rim fixation. However, there was no significant difference in force after the Bankart repair with and without a "bumper" nor after the glenoid rim fixation and glenoid surface-2 mm. The force significantly decreased after scapular neck-2 mm and scapular neck-5 mm compared with the glenoid rim fixation.

CONCLUSION

The anchor fixation on the glenoid face does not increase the translational force compared with the glenoid rim placement, but the placement on the scapular neck decreases the translational force.

MRI graduation of osseous reaction and drill hole consolidation after arthroscopic Bankart repair with PLLA anchors and the clinical relevance

PURPOSE

Conventionally, radiography studies revealed prolonged glenoidal drill hole visibilities with an unclear influence to the clinical outcome after arthroscopic Bankart repair using Poly-Laevo-Lactic-Acid (PLLA) anchors. The primary aim of the present study was the separated assessment of drill hole consolidation (DHC) and the concomitant osseous reaction (OR) of the glenoidal bio-degradation process in new specific magnetic resonance grading systems. In accordance with the specific DHC and the OR graduation, the clinical relevance was the secondary focus.

METHODS

Twenty-eight patients with arthroscopic Bankart repair using knotless PLLA anchors were prospectively followed and analyzed using a clinical scoring system (3, 6, 15 and 32 months). The T2-weighted OR and T1-weighted DHC were assessed using specific magnetic resonance imaging grading protocols (15 and 32 months).

RESULTS

Longitudinal assessments revealed successive clinical status improvements over time (32 months: Rowe 95.7 ± 3.8; Walch-Duplay 93.8 ± 6.6; Constant 93.9 ± 4.5; ASES 93.8 ± 6.9; DASH 28.6 ± 7.2; NAS(pain) 1.1 ± 1.3; NAS(function) 1.3 ± 1.4). The initial OR level regressed over the 15-32 month period while the DHC showed significant drill hole reductions (P < 0.05). The inferior glenoid revealed a significantly increased bio-degradation capacity (P < 0.05) with drill hole enlargements in 14.3%. Neither the OR nor the drill hole enlargements influenced the clinical status. In no case were clinical or radiologic signs for a foreign body reaction.

CONCLUSION

Knotless bio-anchors provide secure glenoidal fixation for Bankart repair without any specific clinical or MR evidence of an inflammatory response. The clinical status remained unaffected by the bio-degradation process.

LEVEL OF EVIDENCE

IV.

FUNCTIONAL ASSESSMENT OF ARTHROSCOPIC REPAIR FOR RECURRENT ANTERIOR SHOULDER INSTABILITY

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

MRI assessment of the structural labrum integrity after Bankart repair using knotless bio-anchors

PURPOSE

Adequate labral restorations after Bankart repair have been demonstrated in cadaver models for knot-tying and knotless anchors and in vivo by magnetic resonance imaging for knot tying. The influence of glenoidal bio-degradation on clinical outcome, and conclusions regarding drill hole enlargement and foreign body reactions remain controversial.

METHODS

The labrum was analyzed in magnetic resonance images for 37 consecutive patients with Bankart repair using knotless PLLA anchors and for 31 volunteers as radiologic controls. The labrum was assessed regarding slope, height index (quotient between labral height to the glenoid height), and labrum morphology in axial and coronal T2 images. Glenoidal bio-degradation was graded in terms of the drill hole configuration in T1 images and the corresponding osseous reaction in T2 images. Constant-Murley, Walch-Duplay, and Rowe scoring were carried out preoperatively and at follow-up.

RESULTS

At 15 months after arthroscopy, the anterior slope (24.8°), height index (3.0), inferior slope (25.4°), and height index (2.5) were not significantly different from control values. Morphologic analysis revealed significant changes in the Bankart group (P < 0.05) that were influenced by the number of preoperative dislocations. Bio-degradation proceeded slowly with no evidence of drill hole enlargement. Osseous reactions were significantly greater in inferior compared to superior implants. The clinical scores were excellent and were not influenced by bio-degradation.

CONCLUSIONS

Knotless anchors facilitate labral restoration that is comparable to the knot-tying approach. Bio-degradation proceeds slowly without clinical or radiologic evidence of foreign body reactions.

LEVEL OF EVIDENCE

III.

Comparison between metal and biodegradable suture anchors in the arthroscopic treatment of traumatic anterior shoulder instability: a prospective randomized study

PURPOSE

The purpose of this study was to compare the clinical outcome of arthroscopic treatment of shoulder instability with metal and biodegradable suture anchors.

METHODS

Arthroscopic stabilization was performed in 78 patients with recurrent traumatic anterior shoulder instability. They were divided into 2 groups of 39 patients each, according to suture anchors used: metal anchors in group 1, and biodegradable anchors in group 2. Results were evaluated by use of the Disabilities of the Arm, Shoulder and Hand (DASH) self-administered questionnaire; Rowe score; Constant score normalized for age and gender, and recurrence of dislocation.

RESULTS

On analyzing the results at a 2-year follow-up, we considered the following independent variables: age; gender; arm dominance; duration of symptoms, age at first dislocation, number of dislocations, type of work; type of sport; sports activity level; lesion of the anterior labrum and anterior-inferior gleno-humeral ligament; SLAP lesion, and number of suture anchors. Comparison between groups did not show significant differences for each variable considered. Overall, according to the results, median DASH scores were 4.5 points (range 0-27) in group 1 and 7 points (range 0-25) in group 2 (n.s.); median Rowe scores were 100 points (range 60-100) and 100 points (range 25-100), respectively (n.s.); and median Constant scores were 98 points (range 81-107) and 98 points (range 87-121), respectively (n.s.). Recurrence was observed in 1 patient (2.8%) in group 1 and in 2 patients (5.9%) in group 2. Overall recurrence rate was 4.3%. Univariate and multivariate analysis showed that age, duration of symptoms, number of dislocations, type of work, and type of sports significantly and independently influenced the outcomes. Differences between groups 1 and 2 were not significant.

CONCLUSION

At a short-term follow-up, differences between arthroscopic shoulder stabilization with metal and biodegradable suture anchors were not statistically significant. Clinical relevance of the study is that there is no difference in the use of metal or biodegradable suture anchors for the arthroscopic treatment of shoulder instability.

Arthroscopic stabilization for first-time versus recurrent shoulder instability

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A 7-year prospective, randomized, clinical, and radiographic study after arthroscopic Bankart reconstruction using 2 different types of absorbable tack

BACKGROUND

Recent studies have shown that techniques for arthroscopic Bankart reconstruction using suture anchors or tacks can equal the results after an open procedure in the treatment of posttraumatic, recurrent, unidirectional shoulder instability. Which kind of technique and which implants to be used still need further study.

PURPOSE

The aim of this study was to compare the clinical and radiographic results after arthroscopic Bankart reconstruction using 2 different types of absorbable implants.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A randomized series of 40 patients who had recurrent shoulder instability underwent reconstruction involving either polygluconate-B polymer or self-reinforced poly-L-lactic acid polymer tack implants. The patients underwent radiographic and clinical assessments preoperatively and at 7 years. Blood levels of C-reactive protein were analyzed preoperatively and postoperatively.

RESULTS

The radiographic visibility of the drill holes was significantly (P = .0001) greater in the poly-L-lactic acid polymer group than in the polygluconate-B polymer group. The failure rate in terms of stability was 5 of 36 (14%) after 7 years and, as previously reported by Magnusson et al, 2 of 40 (5%) after 2 years. Analyses preoperatively and postoperatively of C-reactive protein revealed no significant difference between the groups. No significant differences were found between the groups in terms of strength in abduction, range of motion, and Rowe or Constant scores.

CONCLUSION

Seven years after Bankart repair using either implant, the overall clinical results were satisfactory. The visibility of the drill holes was significantly greater after using poly-L-lactic acid polymer implants.

No difference between knotless sutures and suture anchors in arthroscopic repair of Bankart lesions in collision athletes

The purpose of this study was to compare the clinical results of knotless and knot-tying suture anchors in arthroscopic Bankart repair of collision athletes. Thirty-eight athletes underwent arthroscopic Bankart repairs. The mean age of the patients at the time of surgery was 23 years. Bio-Knot-tying anchors were used in 18 patients, and Bio-Knotless suture anchors were used in 20 patients. Preoperative and postoperative evaluations were performed by Rowe scores. At the end of 40 months follow-up, both the knot-tying and the knotless suture anchor groups had similar postoperative results. There were no differences between Knot-Tying and Knotless repair about late disengagement and re-dislocation in this patient group. Knotless repair provided secure and low-profile repair without introducing complexities to the procedure of arthroscopic knot tying one.

Morphogenetic and regulatory mechanisms during developmental chondrogenesis: new paradigms for cartilage tissue engineering

Cartilage is the first skeletal tissue to be formed during embryogenesis leading to the creation of all mature cartilages and bones, with the exception of the flat bones in the skull. Therefore, errors occurring during the process of chondrogenesis, the formation of cartilage, often lead to severe skeletal malformations such as dysplasias. There are hundreds of skeletal dysplasias, and the molecular genetic etiology of some remains more elusive than of others. Many efforts have aimed at understanding the morphogenetic event of chondrogenesis in normal individuals, of which the main morphogenetic and regulatory mechanisms will be reviewed here. For instance, many signaling molecules that guide chondrogenesis--for example, transforming growth factor-beta, bone morphogenetic proteins, fibroblast growth factors, and Wnts, as well as transcriptional regulators such as the Sox family--have already been identified. Moreover, extracellular matrix components also play an important role in this developmental event, as evidenced by the promotion of the chondrogenic potential of chondroprogenitor cells caused by collagen II and proteoglycans like versican. The growing evidence of the elements that control chondrogenesis and the increasing number of different sources of progenitor cells will, hopefully, help to create tissue engineering platforms that could overcome many developmental or degenerative diseases associated with cartilage defects.

The results of arthroscopic anterior stabilisation of the shoulder using the bioknotless anchor system

Background

Shoulder instability is a common condition, particularly affecting a young, active population. Open capsulolabral repair is effective in the majority of cases, however arthroscopic techniques, particularly using suture anchors, are being used with increasing success.

Methods

15 patients with shoulder instability were operated on by a single surgeon (VK) using BioKnotless anchors (DePuy Mitek, Raynham, MA). The average length of follow-up was 21 months (17 to 31) with none lost to follow-up. Constant scores in both arms, patient satisfaction, activity levels and recurrence of instability was recorded.

Results

80% of patients were satisfied with their surgery. 1 patient suffered a further dislocation and another had recurrent symptomatic instability. The average constant score returned to 84% of that measured in the opposite (unaffected) shoulder. There were no specific post-operative complications encountered.

Conclusion

In terms of recurrence of symptoms, our results show success rates comparable to other methods of shoulder stabilisation. This technique is safe and surgeons familiar with shoulder arthroscopy will not encounter a steep learning curve. Shoulder function at approximately 2 years post repair was good or excellent in the majority of patients and it was observed that patient satisfaction was correlated more with return to usual activities than recurrence of symptoms.

Long-term independent evaluation after arthroscopic extra-articular Bankart repair with absorbable tacks. Surgical technique

BACKGROUND

Several arthroscopic methods have been developed to treat posttraumatic recurrent anterior shoulder instability in an attempt to match the results that can be achieved with open repair. The aim of this study was to perform an independent long-term clinical and radiographic evaluation after extra-articular arthroscopic Bankart repair with use of absorbable tacks (Suretac fixators).

METHODS

Eighty-one consecutive patients with posttraumatic recurrent anterior shoulder instability underwent an extra-articular arthroscopic Bankart procedure. Seventy-one (88%) of the patients were reexamined physically after a median duration of follow-up of 107 months by two independent examiners and constituted the study group. Their clinical and radiographic outcomes were documented.

RESULTS

At the time of follow-up, twenty-seven (38%) of the seventy-one patients had experienced some kind of shoulder instability, although fifteen of them had had a new, clinically relevant shoulder injury. Eleven patients had had subluxation only, and sixteen had had redislocation. Fourteen of the twenty-seven patients had had a single episode of instability. Seven patients had undergone additional surgery to treat shoulder instability. The instability episodes occurred less than two years postoperatively in nine patients, between two and five years postoperatively in twelve, and more than five years postoperatively in six. At the time of final follow-up, the median external rotation in abduction was 90 degrees (range, 0 degrees to 120 degrees ) compared with 95 degrees (range, 70 degrees to 125 degrees ) for the contralateral, uninjured shoulders (p < 0.001). Before the injury, fifty-two patients (73%) participated in overhead or contact sports, whereas thirty-four patients (45%) participated in such activities at the time of follow-up. At the time of follow-up, the drill holes used to implant the absorbable tacks were invisible or hardly visible in fifty-eight (91%) of sixty-four patients for whom radiographs had been made. A marked increase in degenerative changes was noted when follow-up radiographs were compared with the preoperative radiographs.

CONCLUSIONS

This long-term follow-up study of arthroscopic extra-articular Bankart repairs revealed an unexpectedly high number of patients with new episodes of instability. This finding led to a slight modification of the technique. Since most instability episodes occurred after two years, it is important to follow patients for a longer period of time after surgical treatment of recurrent anterior shoulder instability to identify the true recurrence rate.

A long-term clinical follow-up study after arthroscopic intra-articular Bankart repair using absorbable tacks

The aim of the study was to perform an independent long-term evaluation after arthroscopic Bankart repair using absorbable tacks. We hypothesise that arthroscopic Bankart repair using absorbable tacks will result in stable shoulders. Eighty-one consecutive patients (84 shoulders) with symptomatic, recurrent, anterior, post-traumatic shoulder instability were included in the study. All the patients had a Bankart lesion. The age of the patients was 28 (15-62) years. The number of dislocations prior to surgery was five (sublux-50). The operation was performed 28 (3-360) months after the index injury by one of three surgeons with a special interest in shoulder surgery using an intra-articular arthroscopic Bankart procedure involving absorbable Suretac fixators. Seventy-six/84 (90%) of the shoulders (50 male, 23 female patients) were re-examined by two independent observers, after a follow-up period of 98 (46-129) months. In the long-term, the failure rate in terms of stability was 8/76 (11%) dislocations and a further 6/76 (8%) had experienced or had clinical signs of subluxation. The Rowe score was 91 (38-98) points at follow-up and the Constant score was 90 (56-100) points. The Constant score for the contralateral shoulder was 93 (69-100) points (P < 0.001). In the long-term, the arthroscopic Bankart procedure using Suretac fixators resulted in stable, well-functioning shoulders in the majority of patients. Eighteen per cent of the patients had experienced signs of instability during the follow-up period in terms of dislocations or subluxations.

Enlargement of drill holes after use of a biodegradable suture anchor: quantitative study on consecutive postoperative radiographs

PURPOSE

Osteolysis around a biodegradable device has been warned of in several reports. We investigated variations of drill holes of polylactic acid (PLA) suture anchors in consecutive radiographs after arthroscopic capsulolabral repair to assess the influence of enlargement of the drill holes on clinical outcome.

METHODS

Twenty patients who underwent arthroscopic capsulolabral repair using 3 Panalok suture anchors for traumatic anterior shoulder instability were included in the study. The mean follow-up period was 25.8 months. From radiographs taken on postoperative day 1, at 3 and 12 months, and at the latest follow-up, the diameter of each drill hole was measured. The diameter enlargement ratio was calculated for each drill hole by dividing each diameter by the corresponding day-1 diameter. The patients were divided into 2 groups based on the degree of enlargement of drill holes (greater or less than the mean + 1 standard deviation [SD]) and the clinical outcome of each group was evaluated according to the Rowe score and range of motion.

RESULTS

Diameter enlargement ratios tended to increase with time (P = .0152 for 3 v 12 months postoperatively, and P = .0049 for 3 v latest follow-up). Three drill holes out of 53, 17 out of 60, and 11 out of 47 showed enlargement over the mean + 1 SD, at 3 and 12 months postoperatively and at latest follow-up, respectively. Eleven patients had such enlarged drill holes, and had significantly poor Rowe score (70.9 v 95.6 points; P = .0267) at latest follow-up.

CONCLUSIONS

A drill hole filled with a PLA anchor tended to enlarge over time. We found that 55% of patients had at least 1 drill hole that enlarged beyond the mean + 1 SD. These patients had significantly less favorable results in function and stability. The present study raises concern about the use of PLA suture anchors for the fixation of detached glenoid labrum.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.