Editorial Commentary: Recurrence After Arthroscopic Bankart Repair: What the Instability Severity Index Score Will and Will Not Predict

Risk factors for recurrence following arthroscopic Bankart repair: a systematic review

BACKGROUND

Recurrent instability remains a major source of morbidity following arthroscopic Bankart repair. Many risk factors and predictive tools have been described, but there remains a lack of consensus surrounding individual risk factors and their contribution to outcomes. The purpose of this study is to systematically review the literature to identify and quantify risk factors for recurrence following arthroscopic Bankart repair.

METHODS

A literature search was performed using the PubMed/MEDLINE databases based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies were included if they evaluated risk factors for recurrent instability following arthroscopic Bankart repair.

RESULTS

Overall, 111 studies were included in the analysis, including a total of 19,307 patients and 2750 episodes of recurrent instability with 45 risk factors described. Age at operation was reported by 60 studies, with 35 finding increased risk at younger ages. Meta-analysis showed a 2-fold recurrence rate of 27.0% (171 of 634) for patients <20 years old compared with 13.3% (197 of 1485) for older patients (P < .001). Seventeen studies completed multivariable analysis, 13 of which were significant (odds ratio 1.3-14.0). Glenoid bone loss was evaluated by 39 studies, with 20 finding an increased risk. Multivariable analysis in 9 studies found odds ratios ranging from 0.7 to 35.1; 6 were significant. Off-track Hill-Sachs lesions were evaluated in 21 studies (13 significant), with 3 of 4 studies that conducted multivariable analysis finding a significant association with odds ratio of 2.9-8.9 of recurrence. The number of anchors used in repair was reported by 25 studies, with 4 finding increased risk with fewer anchors. Pooled analysis demonstrated a 25.0% (29 of 156) risk of recurrence with 2 anchors, compared with 18.1% (89 of 491) with 3 or more anchors (P = .06). Other frequently described risk factors included glenohumeral joint hyperlaxity (46% of studies reporting a significant association), number of preoperative dislocations (31%), contact sport participation (20%), competitive sport participation (46%), patient sex (7%), and concomitant superior labral anterior-posterior tear (0%).

CONCLUSION

Younger age, glenoid bone loss, and off-track Hill-Sachs lesions are established risk factors for recurrence following arthroscopic Bankart repair. Other commonly reported risk factors included contact and competitive sports participation, number of fixation devices, and patient sex.

Three-dimensional computerized tomography reconstruction-based morphologic assessment of the coracoid process in an Asian population: Clinical implications for shoulder surgery

Purpose

To assess coracoid process morphology in an Asian population using three-dimensional (3D) computed tomography (CT) reconstruction and provide reference values for surgical treatment.

Methods

Data on demographic and shoulder CT characteristics were collected from 142 patients for 3D-CT-based scapular reconstruction. Ten coracoid morphological indicators and the glenoid width were measured. The morphology of the superior pillar and its undersurface were classified into common shapes. Statistical analyses included intraclass correlation coefficient (ICC) analysis, Cohen's κ value, independent samples t test, Welch's t test, Mann-Whitney U test, Kruskal-Wallis test, Spearman and Pearson correlations, receiver operating characteristic (ROC) curves and area under the curve (AUC) values. Relationships among the measured indicators, patient demographics (i.e., sex, age, height and weight) and superior pillar morphology were ascertained.

Results

The intraobserver and interobserver ICC values were 0.924-0.980 and 0.906-0.962, respectively. For intraobserver and interobserver agreement, Cohen's κ values were 0.927-0.950 and 0.901-0.937, respectively. Significant sex differences in coracoid measurements were noted. Correlations were observed between the coracoid indicators and glenoid width, sex, height and weight (p < 0.05). ROC curve analysis identified height as a significant predictor of safe distance, with cutoff values of 160.5 and 170.5 cm (AUC = 0.82 and 0.83) for women and men, respectively. The superior pillar morphologies included violin (24.65%), long rod (21.13%), short rod (33.80%), trapezoidal (11.97%) and wedge (8.45%) shapes, with the undersurfaces categorized as straight (16.20%), arched (76.76%) and hooked (7.04%), with significant differences in pillar widths among the different morphological types (p < 0.05).

Conclusion

Coracoid morphology is crucial in the preoperative planning of given shoulder surgeries, with height and sex serving as key predictors of coracoid graft length. Consideration of variations in the superior pillar shape and undersurface of the coracoid could minimize surgical complications associated with special shoulder surgery.

Level of Evidence

Level IV case series with no comparison.