Fewer anchors achieves successful arthroscopic shoulder stabilization surgery: 114 patients with 4 years of follow-up

Minimum 10-year follow-up outcomes of arthroscopic Bankart’s repair with metallic anchors: Reliable results with low redislocation rates

BACKGROUND

With stiff competition from alternative albeit more expensive counterparts, it has become important to establish the applicability of metallic anchors for shoulder instability in the modern era. This can be accomplished, in part, by analysing long-term outcomes.

AIM

To analyse minimum 10-year outcomes from 30 patients following arthroscopic anterior stabilisation using metallic anchors.

METHODS

Prospectively collected data from arthroscopic Bankart repairs performed using metal anchors during 2007P-2010 were retrospectively analysed in this single-surgeon study. Comprehensive data collection included historical and clinical findings, dislocation details, operative specifics, and follow-up radiological and clinical findings including shoulder scores. The primary outcomes were patient-reported scores (Constant, American Shoulder and Elbow Surgeons [ASES], and Rowe scores) and pain and instability on a visual analogue scale (VAS).

RESULTS

A 3% recurrence rate of dislocation was noted at the final follow-up. Total constant scores at 10 years postoperatively measured between 76 and 100 (mean 89) were significantly better than preoperative scores (mean 62.7). Congruous improvements were also noted in the Rowe and ASES scores and VAS at the 10-year review.

CONCLUSION

Reliable long-term outcomes with metallic anchors in surgery for shoulder instability can be expected. Our results provide additional evidence of their continued, cost-effective presence in the modern scenario.

How many anchors to use in arthroscopic Bankart repairs? A biomechanical study of postage-stamp glenoid fractures

BACKGROUND

Deciding how many anchors to use in a Bankart repair is challenging because of the desire to enhance stability while avoiding a postage-stamp fracture of the glenoid rim.

METHODS

This controlled laboratory study investigated load to fracture of the anterior glenoid rim after drilling holes of varying number and diameter and inserting anchors of 2 different types and sizes, with and without perforation of the medial cortex of the glenoid, creating postage-stamp fractures using a metallic humeral head that was compressed against the anterior glenoid rim. A destructive model with a servohydraulic load frame was used to test 46 synthetic scapulae with compressive strength and elastic modulus similar to that of a human glenoid. Load to fracture of the intact glenoid was compared with groups with a varying number of anchor holes of different diameters, with anchors of different sizes and types, and with anchors perforating or not perforating the glenoid medial cortex. The percentage of force to fracture an intact specimen was used to identify relative risk of fracture: low risk >75%, moderate risk 75%-50%, and high risk <50% of intact load.

RESULTS

The load to fracture of intact glenoids was 1276 ± 42 N. Loads decreased linearly as the number of holes drilled on the glenoid rim increased. Compared with the 1.6-mm group, the 3.0-mm group had significantly lower glenoid rim strength in specimens with 4, 5, and 7 holes (P = .013, .032, and .045, respectively). All-suture anchors in 1.6-mm holes did not alter the glenoid rim strength, and up to 5 anchors were associated with low risk of fracture. Load to fracture was significantly higher with 3.0-mm rigid core bioabsorbable anchors with 4 anchors (1081 ± 6 N) compared with the 4-hole condition (838 ± 107 N; P = .033). Perforating the glenoid medial cortex with five 1.6-mm anchors significantly weakened the glenoid rim to 58% of intact (P = .012). Perforating the medial cortex weakened the glenoid rim to 52% and 42% (P < .001 for both) of intact in the 3.0-mm 4-anchor and 5-anchor constructions, constituting moderate and high risk of fracture, respectively.

CONCLUSION

Up to five 1.6-mm all-suture anchors and four 3.0-mm bioabsorbable rigid-core anchors were associated with low risk of fracture of the glenoid rim. Smaller diameter all-suture anchors best preserved structural integrity of the glenoid rim, whereas tunnel enlargement and perforation of the glenoid medial cortex were associated with moderate or high risk of a postage-stamp fracture.

Lesion prevalence and patient outcome comparison between primary and recurrent anterior shoulder instability

BACKGROUND

The purpose of this study was to compare lesion prevalence and treatment outcomes in patients with primary and recurrent anterior shoulder instability.

METHODS

Patients who were admitted to the institution with a diagnosis of anterior shoulder instability and who underwent arthroscopic surgery between July 2006 and February 2020 were retrospectively evaluated. Minimum follow-up duration of the patients was 24 months. The recorded data and magnetic resonance imaging (MRI) of the patients were examined. Patients aged ≥40 years, with a history of shoulder region fracture, inflammatory arthritis, a history of epilepsy, multidirectional instability, nontraumatic dislocation, and off-track lesions were excluded from the study. Shoulder lesions were documented and patient outcome evaluation was made with the Oxford Shoulder Score (OSS) and visual analog scale (VAS).

RESULTS

A total of 340 patients were included in the study. The mean age of patients was 25.6 years (±6.49). The recurrent instability group had a significantly higher rate of anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions compared to the primary instability group (40.6% vs. 24.6% respectively) (P = .033). Twenty-five patients (43.9%) had superior labrum anterior and posterior (SLAP) lesions in the primary instability group and 81 patients (28.6%) had SLAP lesions in the recurrent instability group (P = .035). OSS increased for both primary (from 35 [16-44] to 46 [36-48]) (P = .001) and recurrent instability groups (from 33 [6-45] to 47 [19-48]) (P = .001). There was no significant difference between the groups regarding postoperative VAS and OSS scores (P > .05).

CONCLUSIONS

Successful results were obtained in patients younger than 40 years with both primary and recurrent anterior shoulder instability after arthroscopic treatment. ALPSA lesion prevalence was higher whereas SLAP lesion prevalence was lower in patients with recurrent instability. Although the postoperative OSS was comparable between the patient groups, the failure rate was higher in the recurrent instability patients.

Arthroscopic Bankart repair: how many knotless anchors do we need for anatomic reconstruction of the shoulder?-a prospective randomized controlled study

PURPOSE

The optimal strategy for surgical repair of traumatic anterior shoulder instability remains controversial. While several study groups have reported that the clinical and radiological outcomes of arthroscopic procedures performed with two anchors are not fully adequate, these conclusions are not supported by the findings published in other studies. A prospective randomized study was conducted to compare the structural and clinical outcomes of surgical procedures involving two vs. three anchors.

METHODS

Patients who underwent arthroscopic Bankart repair were randomly assigned to either Group I, which underwent procedures involving two double-loaded 3.5-mm knotless anchors, or Group II, which underwent procedures involving three single-loaded 2.9-mm knotless anchors. All patients underwent bilateral MRI assessments at a minimum of 12 months and clinical assessment at a minimum of 24 months postoperatively. To evaluate the reconstruction of the labral capsular ligamentous complex (LCLC), the labrum-glenoid height index (LGHI), restored labral height (LH), and labral slope (LS) were measured for both shoulders. For clinical assessment, the redislocation rate and functional outcome scores (Constant score (CS), American Shoulder and Elbow Surgeon score (ASES), Walch Duplay score (WDS), and Rowe score (RS)) were evaluated at follow-up visits.

RESULTS

Bankart repair with two knotless anchors showed lower values for anterior reconstruction of the LCLC compared to the uninjured contralateral shoulder. Likewise, significant differences were noted when comparing these measurements to those from patients who underwent reconstruction with three anchors. No differences were demonstrated with regard to the reconstruction of the inferior LCLC. Clinical assessment showed good to excellent results in both groups. In total, three patients experienced redislocation of the shoulder: two in group I and one in group II. No significant differences were found with respect to clinical outcomes and redislocation rates.

CONCLUSION

Bankart repair with both two and three knotless anchors results in effective anatomical reconstruction of the labral capsular ligamentous complex. Although the two-anchor technique yields significantly lower values for the anterior portion compared with the contralateral side, none of these differences reach clinical relevance as per our original definition.

The "purse string" technique for anterior glenohumeral instability: long-term results 7-13-year follow-up

PURPOSE

The "Purse-String Technique" (PST) is an arthroscopic horizontal mattress suture technique for recurrent anterior shoulder instability that uses a single double-loaded suture anchor at the 4-o' clock position, achieving a Bankart labral repair and an infero-superior capsular shift. In this study, we describe the long-term results of the PST.

METHODS

The study included 69 individuals (70 shoulders), with a mean age of 30 years, who had recurrent post-traumatic anteroinferior instability. A purse-string suture anchor at the 4-o'clock position was used to address the Bankart lesion and capsular laxity, recreating the anterior glenoid bumper. All patients were assessed via telephone interview at a mean of 116 months after surgery (7-13-year follow-up).

RESULTS

Postoperatively, the mean Constant score was 94, mean Rowe score was 93 and mean Walch-Duplay score was 89. 89% of patients resumed their preinjury sport activities, with 61% of patients achieving preinjury levels and most professional athletes returning to full activity. Seven patients had recurrent dislocation postoperatively (10% failure rate). Of these patients, three had revision arthroscopic stabilization, one patient had revision arthroscopic stabilization with remplissage, two had a Latarjet procedure, whereas one patient decided to seek no further treatment.

CONCLUSION

The long-term results of PST are promising, with a low failure rate, high patient satisfaction and a high rate of return to sport.

LEVEL OF EVIDENCE

Level IV; Case series; Treatment study.

Recurrent Instability after Arthroscopic Glenoid Labral Repair with a Minimum of Three Points of Fixation: Do the Number of Anchors or Fixation Points Correlate to Outcomes?

INTRODUCTION

The goal of this study was to evaluate the recurrence rate of instability following arthroscopic Bankart repairs in regard to the number and types of fixation utilized. A Bankart lesion is a tear in the anteroinferior capsulolabral complex within the shoulder, occurring in association with an anterior shoulder dislocation. These injuries can result in glenoid bone loss, decreased range of motion, and recurrent shoulder instability. Successful repair of these lesions has been reported in the literature with repair constructs that have three points of fixation. However, the definition of "one point of fixation" is yet to be fully elucidated.

MATERIALS AND METHODS

A consecutive series of arthroscopically repaired Bankart lesions were evaluated pertaining to the points of fixation required to achieve shoulder stability. This included the number, position, and types of anchors used. Patients consented to complete a series of surveys at a minimum of two years postoperatively. The primary outcome was to determine recurrent instability via the UCLA Shoulder Score, the ROWE Shoulder Instability Score, and the Oxford Shoulder Score. A secondary outcome included pain on a Visual Analog Scale (VAS).

RESULTS

There were 116 patients reviewed, 46 patients achieved three points of fixation in their surgical repair via two anchors and 70 patients achieved a similar fixation with three or more anchors. There was no significant difference in the mean age, gender, or body mass index (BMI). Patients receiving two anchors demonstrated recurrent instability 8.7% of the time (4 of 46 patients). Patients who received three or more anchors demonstrated recurrent instability 8.6% of the time (6 of 70 patients). Overall, there was no statistical significance between the number/types of anchors used. Between the two cohorts, there was no statistically significant difference found between VAS, ROWE, UCLA, and Oxford Scores. There was a significant difference in pain reported on the VAS scale with an average VAS score of 0.43 versus 2.5 in those without and with recurrent instability respectively.

CONCLUSION

Contention still exists surrounding the exact definition of "a point of fixation" in arthroscopic Bankart repairs. Three-point constructs can be created through a variety of combinations including anchors and sutures, ultimately achieving the goal of a stable shoulder.

A comparative study on use of two versus three double-loaded suture anchors in arthroscopic Bankart repair

Objectives

This study aims to compare clinical results of repair using two versus three double-loaded suture anchors in arthroscopic Bankart repair.

Patients and methods

Between July 2012 and December 2017, a total of 40 patients (38 males, 2 females; mean age: 31.6±8.1; range: 17 to 47 years) who underwent Bankart arthroscopic surgery and were followed for minimum two years were retrospectively analyzed. Group 1 (n=17) underwent arthroscopic Bankart repair with two double-loaded suture anchors, while Group 2 (n=23) underwent repair with three double-loaded suture anchors. Clinical outcomes of the patients and recurrences were compared.

Results

At the final postoperative follow-up, a significant improvement was observed in the functional outcomes in all patients. No statistically significant difference was found (p>0.05) in the mean clinical scores of the Constant Shoulder Score between Group 1 (94.2±7.8) and Group 2 (95.4±4.1). There was no significant difference in the mean Rowe scores (Group 1: 95.6±4.6 vs. Group 2: 96.3±3.8, respectively) and external rotation loss (at neutral Group 1: 1.9o vs. Group 2: 2.2o, respectively). Three of our patients had recurrent dislocation during a major traumatic event (n=2 in Group 1 and n=1 in Group 2).

Conclusion

Our study results suggest that stability is not correlated with the use of either two versus three double-loaded suture anchors in arthroscopic Bankart repairs.

Management of Failed Surgery for Anterior Glenohumeral Instability: Synopsis of Clinical Evidence

Failed surgical treatment of anterior shoulder instability should be treated according to clinical principles similar to primary stabilization by addressing risk factors related to the damaged static glenohumeral stabilizers (labrum, capsule and its components, and bony damage to the humeral head and scapular glenoid). In relatively rare conditions when failed primary surgery involves patients with functionally low demands, conservative treatment by strengthening dynamic muscular stabilizers might be considered; otherwise, surgical revision should be strongly considered aimed at improving quality of life. Although the overall failure rate following primary and revision surgery is expected to be below 4%, it is clear that revision surgery is technically demanding. Therefore, the initial recognition and correction of the exact pathology causing glenohumeral instability is crucial to avoid failure of primary surgery and to facilitate the success of the revision procedure, if necessary.

"Postage Stamp" Fractures: A Systematic Review of Patient and Suture Anchor Profiles Causing Anterior Glenoid Rim Fractures After Bankart Repair

PURPOSE

To systematically review patient and technical risk factors for anterior glenoid rim fractures through suture anchor points (i.e. "postage stamp") after arthroscopic Bankart repair.

METHODS

An independent, duplicate search of Embase, Medline, and Web of Science databases, in addition to the past 5-year annual meeting abstracts of several prominent shoulder meetings, was conducted according to R-AMSTAR and Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines to identify English-language studies reporting this complication.

RESULTS

A screen of 2,833 studies yielded 6 for inclusion herein. Data across 43 patients, aged 14 to 61 years (mean 24.4), 5% female, and who were followed for 4 to 108 months postoperatively, were reviewed. Only 1 of 6 studies (n = 2) reported postage stamp fracture in female patients. Median time from initial surgery to fracture ranged from 12 to 24 months. Five of 6 studies (n = 32) reported a median age at initial surgery of 25 years or younger (range 17-35). Four of 6 studies (n = 30) reported fracture mostly after sport involvement. All studies (n = 35) reported initial fixation with a median of 3 anchors or more, 3 of 5 studies (n = 26) reported fracture entirely after conventional knot-tying anchors, and 5 of 6 studies (n = 24) reported more fractures after absorbable suture anchor use. Fractures occurred entirely through anchor holes in 5 of 6 studies (n = 29) and mostly after osteolysis in 3 of 4 studies (n = 19). Management strategies after fracture included revision arthroscopic Bankart repair or open Bristow/Latarjet procedures.

CONCLUSION

Postage stamp fractures were reported frequently in patients who were male, age 25 years or younger, and participants in sporting activities and in fractures initially stabilized with 3 or more anchors or conventional knot-tying anchors or that experienced osteolysis around anchor sites.

LEVEL OF EVIDENCE

Level IV, systematic review of level III and IV studies.

Can capsular plication compensate the lack of one suture anchor in an arthroscopic three suture anchor Bankart repair? A comparative study

Objective

The aim of this study was to compare the complication rates and clinical results of labral repair with two suture anchors and capsular plication, and labral repair with three suture anchor fixation in artroscopic Bankart surgery.

Methods

Sixty-nine patients (60 males, 9 females; mean age: 28.2 ± 7.8 years (range: 16–50)) who had undergone arthroscopic repair of a labral Bankart lesion were evaluated. Group A underwent an arthroscopic Bankart repair with three knotless suture anchors, while group B underwent a modified arthroscopic Bankart repair with two knotless suture anchors and an additional capsular plication procedure. The mean follow-up was 52.5 months. Constant Shoulder Score (CSS), Rowe Score (RS), modified UCLA Shoulder Score (mUSS) and range of motion (ROM) were used as outcome measures.

Results

In both groups, a significant improvement was detected in functional outcomes at postoperative last follow-up compared to the preoperative period. No statistically significant difference was found (p > 0.05) in clinical scores (CSS; Group A: 89.7, Group B: 80.2) (RS; Group A: 88.2, Group B: 80.2) (mUSS; Group A: 26.3, Group B: 25.7) external rotation loss (At neutral; Group A: 4.5°, Group B: 5.2°. At abduction; Group A: 4.3°, Group B: 5.7°) and recurrence rates (Group A: 13.3%, Group B: 20.8%). Although the difference was not statistically significant, the recurrence rate was higher in group B (20.8%), compared to group A (13.3%), despite the shorter average follow-up time of group B (p = 0.417).

Conclusions

Arthroscopic repair of labral Bankart lesions with both techniques showed good functional outcomes and stability at the latest follow-up. Higher recurrence rate despite the shorter average follow-up of group B suggests that two anchor usage might not be sufficient for Bankart repair in terms of better stability and less recurrence risk.

Level of evidence

Level III, Therapeutic Study.

Recurrent Instability After Arthroscopic Bankart Reconstruction: A Systematic Review of Surgical Technical Factors

PURPOSE

Recurrent instability remains of concern after arthroscopic Bankart reconstruction. We evaluated various technical factors including anchor design, anchor material, number of anchors used, and interval closure on risk of recurrent instability after arthroscopic Bankart reconstruction.

METHODS

A systematic review of MEDLINE and Cochrane databases was conducted, following PRISMA guidelines. Extracted data were recorded on a standardized form. Methodological index for non-randomized studies (MINORS) and Newcastle-Ottawa Scale (NOS) were used to assess study quality and risk bias. Because of study heterogeneity and low levels of evidence, meta-analysis was not possible. Pooled weighted means were calculated and individual study evaluation and comparisons (qualitative analysis) were performed for systematic review.

RESULTS

Of 2097 studies identified, 26 met criteria for systematic review. Pooled weighted means revealed 11.4% versus 15% recurrent instability with 3 or more suture anchors versus fewer than 3 anchors, 10.1% versus 7.8% with absorbable versus nonabsorbable suture anchors, respectively, and 8.0% versus 9.4% with knotless versus standard anchors, respectively. Interval closure did not qualitatively decrease recurrent instability or decrease range of motion.

CONCLUSIONS

Our systematic review reveals that despite individual study, and previous systematic reviews pointing to the contrary, the composite contemporary published literature would support no difference in the risk of recurrent instability after arthroscopic Bankart reconstruction with rotator interval closure, differing numbers of anchors used for the repair, use of knotless versus standard anchors, or use of bioabsorbable versus nonabsorbable anchors. We recommend surgeons focus on factors that have been shown to modify the risk factors after arthroscopic Bankart reconstruction, such as patient selection.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

The "Purse String" Procedure for Recurrent Anterior Glenohumeral Instability: A Simple Technique to Achieve Bankart Repair, Capsular Shift, and a Good Labral Bumper

Failure of arthroscopic techniques in cases of recurrent anterior glenohumeral instability may result from inadequate treatment of capsular injury. The use of few anchors has been cited as a cause of failure in arthroscopic stabilization techniques. This applies to the use of the suture anchors as spot-welding points in conventional techniques. It has been shown that horizontal mattress suture techniques restore better labral height and anatomy than simple suture techniques in the repair of acute Bankart lesions. Horizontal mattress repairs, like the one achieved with the "purse-string" technique, pushes the labrum toward the humeral side of the joint, thus providing a buttress to the glenohumeral joint. We present the purse-string technique, which involves the use of only 1 suture anchor located at the 4-o'clock position. Sutures are passed through the labrum and capsule from south to north, thus allowing the incorporation of more capsular tissue involved in the raising of the anterior labral bumper. One suture anchor at the 4-o'clock position is used to ensure a purse-string effect, with tightening of the capsule in the inferosuperior plane and repair of the Bankart lesion. The repair achieved is 3-fold: Bankart repair, south-to-north capsular shift, and creation of an anterior bumper.

The "Purse-string" Technique for Shoulder Stabilization, Description of the Technique, Long term Results and Literature Review

BACKGROUND

Over the last 2 decades arthroscopic stabilization and Bankart repair has gained popularity due to the advances in materials and surgical techniques. Results of arthroscopic stabilization have been similar to open without the risks of it. The number of anchors used has been suggested to be very important in "spot-weld" arthroscopic stabilization however the "purse-string" technique (PST) can achieve similar results using only one anchor. We describe technique and long term results from using the PST and search the literature for other papers regarding PST.

METHODS

Between 2003 and 2013 a total of 193 patients were operated. Patients included those with anterior instability. Using PubMed relevant studies reporting results of PST were identified.

RESULTS

Mean follow up was 2 (range 0.5 to 3) years. 9 (4.7%) patients experienced recurrent instability. Almost all patients (97%) returned to their sporting and leisure activities and all professional athletes went back to the same sport. One more UK centre reported 6.1% recurrence in 114 patients at 4 years follow up. These results are similar to the published 11% recurrence of instability after "spot-weld" arthroscopic techniques at 11 years clinical follow-up.

CONCLUSION

This study indicates that PST is safe and effective alternative method for the treatment of anterior shoulder instability. In this technique with one anchor simultaneous repair of labrum, creation of an anterior bumper and capsular shift can be achieved. It has the advantage of being cheaper, faster yet efficient with good long term results and leaves space for revision anchors in case of recurrence.

Results of Arthroscopic Bankart Repair for Anterior-Inferior Shoulder Instability at 13-Year Follow-up

BACKGROUND

Anterior-inferior shoulder instability is a common injury in young patients, particularly those practicing overhead-throwing sports. Long-term results after open procedures are well studied and evaluated. However, the long-term results after arthroscopic repair and risk factors of recurrence require further assessment.

HYPOTHESIS

Arthroscopic Bankart repair results are comparable with those of open repair as described in the literature.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 180 shoulders with anterior-inferior shoulder instability were stabilized arthroscopically, met the inclusion criteria and the patients were able to be contacted at a minimum of 10-year follow-up. Of these patients, 143 agreed to participate in the study. Assessment was performed clinically in 104 patients using the American Shoulder and Elbow Surgeons score, Constant score, American Academy of Orthopaedic Surgeons score, Rowe score, and the Dawson 12-item questionnaire. The Samilson-Prieto score was used to assess degenerative arthropathy in radiographs available for 100 shoulders. Additionally, 15 patients participated through a specific questionnaire and 24 patients through a telephone survey.

RESULTS

The overall redislocation rate was 18.18%. Redislocation rates for the different types of fixation devices were as follows: FASTak/Bio-FASTak, 15.1% (17/112); SureTac, 26.3% (5/19); and Panalok, 33.3% (4/12). Concomitant superior labral anterior-posterior repair had no effect on clinical outcome. Redislocation rate was significantly affected by the patient's age and duration of postoperative rehabilitation. Redislocation rate tended to be higher if there had been more than 1 dislocation preoperatively ( P = .098). Severe dislocation arthropathy was observed in 12% of patients, and degenerative changes were significantly correlated with the number of preoperative dislocations, patient age, and number of anchors. The patient satisfaction rate was 92.3%, and return to the preinjury sport level was possible in 49.5%.

CONCLUSION

Clinical outcome at a mean follow-up of 13 years after arthroscopic repair of anterior-inferior shoulder instability is comparable with the reported results of open Bankart repair in the literature and allows management of concomitant lesions arthroscopically. Modifiable risk factors of postoperative redislocation and arthropathy must be considered. Stabilization after the first-time dislocation achieves better clinical and radiological outcomes than after multiple dislocations.

The results of Bankart repair without capsular plication in patients with recurrent traumatic anterior shoulder dislocation

PURPOSE

The aim of this study was to evaluate the results of patients with recurrent anterior shoulder dislocation, who had been treated with repair of the Bankart lesion without capsuler plication.

MATERIAL AND METHOD

The study included 22 shoulders of 22 patients (16 males and 6 females) with a mean age of 28 years, who underwent Bankart repair between 2011 and 2014. Patients with bilateral shoulder instability, multiple instability, >25% glenoid bone loss, and those with a history of shoulder surgery were not included in the study. The average follow-up time was 21.2 months. Evaluation was made of the preoperative number of dislocations, postoperative recurrence, functional status, and daily activity performance of the patients. Shoulder range of motion was measured. The results were evaluated using the Rowe shoulder score and the Oxford shoulder instability score.

RESULTS

Recurrence was observed in only one patient who had a shoulder dislocation after trauma, thus giving a recurrence rate of 4.5%. Shoulder range of motion was full in all except that one patient. The mean Rowe shoulder score was 95.5 (excellent) and Oxford shoulder stability score was 44.6 (excellent).

CONCLUSION

No recurrent shoulder dislocation was observed in patients who underwent Bankart repair surgery. Plication was not performed with the Bankart repair. Close to full range of motion was obtained in all patients. In conclusion, Bankart repair alone can be considered to be sufficient for the treatment of traumatic recurrent anterior shoulder instability.

Management of shoulder instability: the current state of treatment among German orthopaedic surgeons

INTRODUCTION

The aim of this study was to evaluate the current state of treatment in traumatic anterior shoulder dislocation in Germany and to detect changes over the last 12 years.

METHODS

Seven hundred ninety-six trauma and/or orthopaedic departments were found in the German hospital directory 2012. The websites of each department were searched for the email address of the responsible shoulder surgeon (if applicable) or the head of the department. Seven hundred forty-six email addresses were found, and emails with the request to participate in an online survey were sent in January 2013. Six hundred seventy-five emails probably reached the correct addressee. Seventy-one emails were rejected, and no contact could be made. One-hundred ninety-one (28 %) participated in the study. The data were compared to similar data from a survey on shoulder dislocation performed in the same department and published in 2001.

RESULTS

After the first-time traumatic shoulder dislocation in patients aged younger than 30 years participating in sports, 14 % of the participants would prefer conservative treatment, 83 % arthroscopic, and 3 % open surgery. When surgery was indicated, arthroscopic Bankart repair was the treatment of choice for 93 % of the participants. In 2001, 27 % had indicated conservative treatment after the first-time shoulder dislocation in active patients younger than 30 years. When surgery was indicated, 66 % had performed arthroscopic and 34 % open stabilization. For the standard arthroscopic Bankart repair without concomitant injuries, 41 % of the participants use two and 54 % three suture anchors. Knotless anchors were preferred by 72 %. In the case of glenoid bone loss greater than 25 %, only 46 % perform a procedure for glenoid bone augmentation. Fifteen percent of the participants always recommended immobilization in external rotation after traumatic first-time shoulder dislocation.

CONCLUSIONS

The majority of participants recommend arthroscopic Bankart repair with two or three suture anchors in young persons with the first-time dislocations. Compared to 2001 less recommend conservative treatment, complex "open" surgical procedures are no longer used. The knowledge that a Bankart procedure likely fails in significant glenoid bone loss is not implemented in the clinical practice. Thus, there is a need to educate surgeons on this topic.

Arthroscopic Bankart repair: Have we finally reached a gold standard?

Traditionally, surgical stabilization of the unstable shoulder has been performed through an open incision. Arthroscopic Bankart repair with suture anchors is now widely considered the treatment of choice for anterior shoulder instability in patients who have failed conservative management. Many different factors have now been elucidated for adequate treatment of glenohumeral instability. Because of technical advances in instability repair combined with an increased understanding of factors that lead to recurrent instability, the outcomes following arthroscopic Bankart repair have significantly improved and approach those of open techniques.

Anterior Glenoid Rim Fracture Following Use of Resorbable Devices for Glenohumeral Stabilization

BACKGROUND

Resorbable anchors are widely used in arthroscopic stabilization of the shoulder as a means of soft tissue fixation to bone. Their function is to ensure repair stability until they are replaced by host tissue. Complications include inflammatory soft tissue reactions, cyst formation, screw fragmentation in the joint, osteolytic reactions, and enhanced glenoid rim susceptibility to fracture.

PURPOSE

To evaluate resorption of biodegradable screws and determine whether they induce formation of areas with poor bone strength that may lead to glenoid rim fracture even with minor trauma.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study evaluated 12 patients with anterior shoulder instability who had undergone arthroscopic stabilization with the Bankart technique and various resorbable anchors and subsequently experienced redislocation. The maximum interval between arthroscopic stabilization and the new dislocation was 52 months (mean, 22.16 months; range, 12-52 months). The mean patient age was 31.6 years (range, 17-61 years). The persistence or resorption of anchor holes; the number, area, and volume of osteolytic lesions; and glenoid erosion/fracture were assessed using computed tomography scans taken after redislocation occurred.

RESULTS

Complete screw resorption was never documented. Osteolytic lesions were found at all sites (mean diameter, 5.64 mm; mean depth, 8.09 mm; mean area, 0.342 cm(2); mean volume, 0.345 cm(3)), and all exceeded anchor size. Anterior glenoid rim fracture was seen in 9 patients, even without high-energy traumas (75% of all recurrences).

CONCLUSION

Arthroscopic stabilization with resorbable devices is a highly reliable procedure that is, however, not devoid of complications. In all 12 patients, none of the different implanted anchors had degraded completely, even in patients with longer follow-up, and all induced formation of osteolytic areas. Such reaction may lead to anterior glenoid rim fracture according to the literature and as found in 75% of the study patients with local osteolysis (9/12). Reducing anchor number and/or size may reduce the risk of osteolytic areas and anterior glenoid rim fracture.

Prevalence of and Risk Factors for Dislocation Arthropathy: Radiological Long-term Outcome of Arthroscopic Bankart Repair in 100 Shoulders at an Average 13-Year Follow-up

BACKGROUND

Glenohumeral osteoarthritis is a well-documented, long-term complication of open stabilization procedures. However, there is a lack of knowledge about long-term radiographic outcome after arthroscopic Bankart procedures.

HYPOTHESIS

Glenohumeral osteoarthritis will develop less frequently in arthroscopic Bankart repair compared with open repairs reported in the literature.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

The inclusion criteria for this study were (1) all-arthroscopic Bankart repair for a (2) symptomatic anteroinferior shoulder instability and (3) a minimum follow-up of 10 years. True anteroposterior and lateral radiographs were obtained to evaluate the prevalence and grade of osteoarthritis according to the Samilson classification. Patients were assessed by the Constant score and examined for passive external rotation deficits.

RESULTS

Of 165 shoulders that fulfilled the inclusion criteria, 100 were available for evaluation. The median Constant score at an average±SD 156.2±18.5 months after Bankart repair was 94 (range, 46-100). Twenty-one shoulders (21%) sustained a recurrent dislocation. Overall, 31% of shoulders showed no evidence of glenohumeral osteoarthritis; 41% showed mild, 16% moderate, and 12% severe degenerative changes. Osteoarthritis did not correlate with Constant score results (P=.427). The grade of osteoarthritis was significantly associated with the number of preoperative dislocations (P=.016), age at initial dislocation (P=.005) and at surgery (P=.002), and the number of anchors used (P=.001), whereas time from initial dislocation to surgery (P=.854) and external rotation deficit at 0° and 90° of abduction (P=.104 and .348, respectively) showed no significant correlation. Recurrent dislocation did not affect the presence or grade of osteoarthritis (P=.796 and .665, respectively).

CONCLUSION

At an average 13 years after arthroscopic Bankart repair, osteoarthritic changes are a common finding and, overall, are comparable with reports in the literature regarding open procedures as well as nonoperative treatment. The extent of trauma sustained during preoperative dislocations and the age of the patient seem to be more relevant for long-term dislocation arthropathy than the kind of treatment. Accordingly, the study hypothesis must be rejected. Avoiding preoperative dislocations is more important for the prevention of osteoarthritis than short-term treatment. The number of anchors used was found to be a predictor for long-term development of osteoarthritis.