Arthroscopic treatment of posterior shoulder instability: results in 33 patients

BACKGROUND: Posterior shoulder instability is a relatively rare condition and a surgical challenge. Arthroscopic techniques have allowed for a potential improvement as well as diagnosis and management of this condition. PURPOSE: To evaluate the outcomes of arthroscopic posterior shoulder stabilization and to evaluate preoperative and intraoperative variables as predictors of success. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty-three consecutive patients with a mean age of 25 years (range, 19-34 years) who underwent posterior arthroscopic shoulder stabilization with suture anchors (mean, 3 anchors) or suture capsulolabral plication (mean, 5.3 stitches) or both were reviewed at a mean follow-up of 39.1 months (range, 22-60 months). Shoulder outcomes rating scores were determined using the American Shoulder and Elbow Surgeons Rating Scale, the Western Ontario Shoulder Instability Index, the Subjective Patient Shoulder Evaluation, and the Single Assessment Numeric Evaluation. RESULTS: There were 7 failures: 4 for recurrent instability and 3 for symptoms of pain. Overall, outcomes scores demonstrated mean values of the American Shoulder and Elbow Surgeons Rating Scale of 94.6, Subjective Patient Shoulder Evaluation of 20.0, Western Ontario Shoulder Instability Index of 389.4 (81.5% of normal), and Single Assessment Numeric Evaluation of 87.5. Patients with voluntary instability demonstrated worse outcomes (P = .025), and those with prior surgery of the shoulder also did worse (P = .02). CONCLUSION: Arthroscopic treatment of posterior shoulder instability is an effective means to improve symptoms associated with recurrent posterior subluxation of the shoulder. It can provide predictable success in the setting of unidirectional, nonvoluntary posterior instability without prior surgery.     

The modified Bristow procedure for anterior shoulder instability: 26-year outcomes in Naval Academy midshipmen

BACKGROUND: Many procedures have been proposed for the correction of anterior shoulder instability. Some of these procedures address the problem anatomically, such as the Bankart procedure, and some prevent instability nonanatomically, such as the Bristow-Latarjet procedure. A modified Bristow procedure was the procedure of choice for anterior shoulder instability among midshipmen at the United States Naval Academy from 1975 to 1979. HYPOTHESIS: The modified Bristow procedure for anterior shoulder instability provides good shoulder function and stability in the long term. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: There were 52 shoulders in 49 patients reviewed at a mean follow-up of 26.4 years. The Rowe score, Single Assessment Numeric Evaluation, and Western Ontario Shoulder Instability Index were used to assess outcomes. RESULTS: The mean Rowe score was 81.8 (range, 5-100), and the mean Single Assessment Numeric Evaluation score was 82.9 (range, 30-100), with an overall Single Assessment Numeric Evaluation of 71.2% (37 of 52 shoulders) rated as good and excellent. The mean Western Ontario Shoulder Instability Index was 376 of 2100 (range, 0-1560). Overall, recurrent instability occurred in 8 of 52 shoulders (15.4%), with recurrent dislocation in 5 shoulders (9.6%) and recurrent subluxation in 3 shoulders (5.8%). The mean time to recurrent dislocation was 7.0 years. CONCLUSION: This study represents the longest follow-up in the literature of the modified Bristow procedure. The authors have shown nearly 70% good and excellent results and recurrent instability comparable with other long-term follow-up studies of open instability procedures.     

Arthroscopic stabilization in patients with an inverted pear glenoid: results in patients with bone loss of the anterior glenoid

BACKGROUND: Recent literature has demonstrated that the success rates of arthroscopic stabilization of glenohumeral instability deteriorate in patients with an anteroinferior glenoid bone deficiency, also known as the "inverted pear" glenoid. PURPOSE: This study was conducted to assess the outcomes of arthroscopic stabilization for recurrent anterior shoulder instability in patients with a mean anteroinferior glenoid bone deficiency of 25% (range, 20%-30%). STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Twenty-one of 23 patients (91% follow-up) undergoing arthroscopic stabilization surgery and noted to have a bony deficiency of the anteroinferior glenoid of 20% to 30% were reviewed at a mean follow-up of 34 months (range, 26-47). The mean age was 25 years (range, 20-34); 2 patients were female and 19 were male. All patients were treated with a primary anterior arthroscopic stabilization using a mean of 3.2 suture anchors (range, 3-4). Eleven patients had a bony Bankart that was incorporated into the repair; 10 had no bone fragment and were considered attritional bone loss. Outcomes were assessed using the Rowe score, the American Shoulder and Elbow Surgeons (ASES) Score, the Single Assessment Numeric Evaluation (SANE), and the Western Ontario Shoulder Instability (WOSI) Index. Findings of recurrent instability and dislocation events were documented. RESULTS: Two patients (9.5%) experienced symptoms of recurrent subluxation, and 1 (4.8%) sustained a recurrent dislocation that required revision open surgery. The mean postoperative outcomes scores were as follows: SANE = 88.1 (range, 65-100; standard deviation [SD] 9.0); Rowe = 85.2 (range, 55-100; SD 14.1); ASES Score = 93.1 (range, 78-100; SD 5.3); and WOSI Index = 398 (82% of normal; range, 30-1175; SD 264). No patient with a bony fragment experienced a recurrent subluxation or dislocation, and mean outcomes scores for patients with a bony fragment were better than those with no bony fragment (P = .08). No patient required medical discharge from the military for his or her shoulder condition. CONCLUSIONS: Arthroscopic stabilization for recurrent instability, even in the presence of a significant bony defect of the glenoid, can yield a stable shoulder; however, outcomes are not as predictable especially in attritional bone loss cases. Longer-term follow-up is needed to see if these results hold up over time.     

Long-term results of arthroscopic Bankart repair with a bioabsorbable tack

BACKGROUND: Short-term to midterm data are available on arthroscopic shoulder stabilization using bioabsorbable tacks or suture anchors. It remains unknown whether these techniques can equal the success of open Bankart repair in the long term. PURPOSE: To assess the long-term outcome of arthroscopic Bankart repair using bioabsorbable tacks in patients with traumatic anterior shoulder instability with a minimum follow-up of 7 years. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Treatment outcomes were determined prospectively according to the Rowe score and retrospectively according to the Constant and American Shoulder and Elbow Surgeons scores. Included in this study were 18 consecutive patients with a mean age of 26.8 years (range, 16-62 years) who underwent arthroscopic Bankart repair using bioabsorbable tacks for traumatic anterior shoulder instability. The study group consisted of 14 male and 4 female patients. The mean follow-up was 8.7 years (range, 7.0-9.8 years). RESULTS: One patient had recurrent dislocations requiring further surgery, for an overall failure rate of 5.6%. An additional patient had 1 traumatic subluxation episode within the first postoperative year that did not recur. According to the Rowe score, which increased to 90.3 (17.8) from 32.8 (8.3) points preoperatively, 15 patients (83.3%) achieved a good or excellent result. The mean Constant score was 91.3 (SD, 6.9) points, and the mean American Shoulder and Elbow Surgeons score was 92.1 (SD, 6.9) points postoperatively. A return to the preinjury level of sports competition was reported by 64% of patients. No signs of synovitis occurred in any patient postoperatively. CONCLUSION: Arthroscopic Bankart repair for the treatment of recurrent traumatic anterior shoulder instability repair using bioabsorbable tacks offers reliable results with respect to failure rate, range of motion, and shoulder function during a minimum follow-up of 7.0 years. In contrast to previous reports on arthroscopic Bankart repair, results did not deteriorate during follow-up.     

Structural integrity and clinical function of the subscapularis musculotendinous unit after arthroscopic and open shoulder stabilization

BACKGROUND: Postoperative subscapularis dysfunction after open shoulder stabilization has recently received increasing attention. The potential advantage of arthroscopic stabilization procedures is that they do not violate the subscapularis musculotendinous unit, which might preserve its structural integrity and clinical function, which would lead to superior clinical results. HYPOTHESIS: Arthroscopic shoulder stabilization does not lead to clinical and radiological signs of subscapularis insufficiency. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Twenty-two patients who underwent arthroscopic (group I, n = 12; average age, 30.9 years; mean follow-up, 37 months) or open (group II, n = 10; average age, 28.8 years; mean follow-up, 35.9 months) shoulder stabilization procedure were followed up clinically (clinical subscapularis tests and signs, Constant Score, Rowe Score, Walch-Duplay Score, Western Ontario Shoulder Instability Index and Melbourne Instability Shoulder Score) and by magnetic resonance imaging (subscapularis tendon integrity, cross-sectional area, defined muscle diameters, and signal intensity analysis [ratio infraspinatus/upper subscapularis and infraspinatus/lower subscapularis]). A third group (group 0) of 12 healthy volunteers served as a control. RESULTS: Clinical signs for subscapularis insufficiency were present in 0% of cases in group I and in 70% of cases in group II. There were no statistically significant differences in either group regarding Constant Score, Rowe Score, Walch-Duplay Score, Western Ontario Shoulder Instability Index, and Melbourne Instability Shoulder Score (P > .05). On magnetic resonance image, no subscapularis tendon ruptures were found. The cross-sectional area, the mean vertical diameter, and the mean transverse diameter of the upper and lower subscapularis muscle portion was significantly less in group II than in group 0 (P < .05). The signal intensity analysis revealed the infraspinatus/upper subscapularis ratio was significantly lower in group II than in group I or group 0. The infraspinatus/lower subscapularis ratio did not significantly differ in all 3 groups (P > .05). CONCLUSION: This study confirms previous observations that open shoulder stabilization using a subscapularis tenotomy may lead to atrophy and fatty infiltration of the subscapularis muscle, resulting in postoperative subscapularis dysfunction. As expected, arthroscopic procedures do not significantly compromise clinical subscapularis function and structural integrity. However, no significant differences were observed in the overall outcome.     

Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for Recurrent Anterior instability of the shoulder: a meta-analysis

BACKGROUND: In published comparative studies, it remains unknown if arthroscopic techniques for performing Bankart repair for anterior shoulder instability equal the success of open repair. HYPOTHESIS: The current literature supports a lower rate of recurrent instability after open Bankart repair compared to arthroscopic repair with bioabsorbable tacks or transglenoid sutures. STUDY DESIGN: Meta-analysis. METHODS: A Medline search identified all randomized controlled trials or cohort studies that directly compared open repair to arthroscopic techniques of Bankart repair for traumatic, unilateral, recurrent anterior instability. Data collected from each study included patient demographics, surgical technique, rehabilitation, outcome, and complications. RESULTS: Six studies met all inclusion criteria. There were 172 patients in the arthroscopic group (90 patients with transglenoid sutures, 77 patients with arthroscopic tacks, and 5 patients with suture anchors) and 156 patients in the open group. The groups were similar in demographic characteristics. When comparing the arthroscopic to the open group, there was a significantly higher rate of recurrent dislocation (12.6% vs 3.4%; P = .01) and total recurrence (recurrent dislocation or subluxation) (20.3% vs 10.3%; P = .01). In addition, there was a higher proportion of patients with an excellent or good postoperative Rowe score in the open group (88%) than in the arthroscopic group (71%) (P = .01). CONCLUSIONS: Arthroscopic Bankart repair using transglenoid sutures or bioabsorbable tacks results in a higher rate of recurrence of instability compared to open techniques. Studies comparing open repair to newer arthroscopic techniques using suture anchor fixation and capsular plication are necessary.     

Arthroscopic versus open shoulder stabilization for recurrent anterior instability: a prospective randomized clinical trial

BACKGROUND: Arthroscopic stabilization for anterior shoulder instability has been reported to result in a higher rate of recurrent instability compared to traditional open techniques. PURPOSE: To test the null hypothesis that there is no difference in the clinical outcomes in patients with recurrent anterior shoulder instability treated with open or arthroscopic stabilization. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Magnetic resonance arthrogram studies were obtained preoperatively. These findings were compared to arthroscopic findings. Postoperative evaluations included range of motion, stability, and subjective assessments including Single Assessment Numeric Evaluation, Simple Shoulder Test, Western Ontario Instability Index, and University of California, Los Angeles evaluation. Failure was defined as a second dislocation, recurrent subluxation, or symptoms precluding return to previous work or unrestricted active military duty. RESULTS: Sixty-one patients, 29 who received open stabilization and 32 who received arthroscopic stabilization, were evaluated at a mean of 32 months postoperatively (range, 24-48 months). Patient demographics were equivalent. Preoperative magnetic resonance arthrogram findings were confirmed at arthroscopic examination. The mean operative time was significantly shorter for the arthroscopic repairs (59 vs 149 minutes; P < .001). There were 3 clinical failures (2 open stabilizations, 1 arthroscopic stabilization) by the established criteria. There was a statistically significant improvement from preoperative to postoperative Single Assessment Numeric Evaluation scores in both groups (P < .001). The mean loss of motion (compared to the contralateral shoulder) was greater in the open shoulders. Subjective evaluations were equal in both groups. Conclusion: Clinical outcomes after arthroscopic and open stabilization were comparable. Preoperative magnetic resonance arthrograms in shoulders with anterior instability allow an accurate diagnosis of intra-articular abnormality that correlates well with operative findings. Arthroscopic stabilization for recurrent anterior shoulder instability can be performed safely; the clinical outcomes are comparable to those after traditional open stabilization.     

Quantitative assessment of glenohumeral translation after anterior shoulder dislocation and subsequent arthroscopic bankart repair

BACKGROUND: During the past decade, developments in arthroscopic technology have made arthroscopic repair of labral lesions feasible. However, results with the use of the transglenoid suture technique, or with the use of bioabsorbable tacks, have remained variable in the literature, and the recurrence rates are still inferior to those of open Bankart repair. HYPOTHESIS: Arthroscopic Bankart repair with suture anchors can re-create translational and rotational range of motion of the intact glenohumeral joint, and the number of preoperative dislocations has an influence on the result. STUDY DESIGN: Controlled laboratory study. MATERIALS: Twelve cadaveric shoulders were tested in a robot-assisted shoulder simulator. Anterior and posterior translation and external rotation were measured for intact, dislocated (shoulders were randomly selected to 1 of 3 groups, which were dislocated 1, 3, or 7 times), and repaired conditions at 0 degrees and 90 degrees of glenohumeral elevation. RESULTS: After shoulder dislocation, a significant increase was found in translation and rotation, confirming the creation of a traumatic shoulder instability model. Further testing of the specimen revealed that translational and rotational ranges of motion were reduced by arthroscopic Bankart repair at both testing positions. External rotation was decreased significantly at 0 degrees and 90 degrees of abduction. No significant differences were found between the 3 dislocation groups. CONCLUSION: The results demonstrate a sufficient biomechanical performance of arthroscopic Bankart repair using suture anchors in a traumatic anterior shoulder instability model. With the numbers available, no relationship was found between the number of dislocations and the postoperative result concerning translational or rotational motion. CLINICAL RELEVANCE: Glenohumeral translation and rotation after arthroscopic Bankart repair with use of suture anchors approached near normal values, confirming the clinical success of this technique.     

Bony Bankart is a positive predictive factor after primary shoulder dislocation

It would be a great advantage if it were possible to categorise the patients with first time dislocations to an initial treatment with the most beneficial outcome. MRI could be a useful method for finding lesions after shoulder dislocation. Fifty-eight patients with traumatic anterior shoulder dislocation were treated by closed reduction and were examined by MRI after a maximum of 2 weeks. The hemarthrosis or effusion present in the joint after the primary dislocation could be used as a contrast for arthrography to identify the lesions present on MRI. At follow-up more than 8 years later, the MRI findings were compared to the shoulder function, shoulder stability, Rowe score and Western Ontario Shoulder Instability Index (WOSI). Besides the age of the patient being above 30, the MRI findings analysed showed that an isolated fracture of the major tubercle, as well as a bony Bankart lesion are prognostic factors for a good functional result and a stable shoulder after a primary dislocation. The glenoid rim fracture was only detected on plain radiographs in 6 out of 10 findings on MRI. MRI findings of a gleniod rim fracture, equal to a bony Bankart lesion, were found to be a prognostic factor for stability and a good functional outcome.     

The surgical outcome of immediate arthroscopic Bankart repair for first time anterior shoulder dislocation in young active patients

This study evaluated the surgical outcomes of young active patients with arthroscopic Bankart repair within 1 month after first-time anterior shoulder dislocation. From July 2002–October 2004, patients presented with first-time traumatic anterior shoulder dislocation and treated with arthroscopic stabilization within 1 month of injury were retrospectively reviewed. Magnetic resonance imaging and computed tomography were performed before the operation in all cases. Cases with contralateral shoulder multidirectional instability or glenoid bone loss of more than 30% on preoperative computed tomography on the injury side were excluded. All patients were treated with arthroscopic Bankart repair, using metallic suture anchors or soft tissue bio-absorbable anchors by a same group of surgeons and followed the same rehabilitation protocol. Recurrence, instability signs, range of motion, WOSI score, Rowe score and complications were assessed. Thirty-eight patients were recruited: the average age was 21 (16–30). All patients had definite trauma history. Radiologically, all patients had Bankart/Hill-Sachs lesion. All the operations were done within 1 month after injury (6–25 days). The average hospital stay was 1.2 days (1–5 days). The average follow-up was 28 months (24–48 months). There were two cases of posttraumatic re-dislocation (5.2%). The average external rotation lag was 5° (0–15) in 90° shoulder abduction when compared with contralateral side. 95% of patients had excellent or good Rowe score. The average WOSI score was 83%. There was one case of transient ulnar nerve palsy and one case of superficial wound infection. This study concluded that immediate arthroscopic Bankart repair with an accelerated rehabilitation program is an effective and safe technique for treating young active patients with first-time traumatic anterior shoulder dislocation. This study complies with the current laws of the Hong Kong Special Administration Region Government.     

关节镜下盂唇修补合并改良Remplissage术治疗伴Hill-Sachs损伤肩关节前方不稳的临床对照研究

目的:研究盂唇修补合并改良Remplissage手术治疗伴肱骨头中小型Hill-Sachs骨性缺损的创伤性复发性肩关节前方不稳的疗效。方法:选取2006年至2010年经影像学检查确诊为伴肱骨头中小型Hill-Sachs损伤的创伤性复发性肩关节前方不稳患者共42例行回顾性随访研究。所有患者均由同一名医生施行关节镜下前方稳定术。根据是否加用改良Remplissage术式分为A、B两组。A组26例,在2006年至2009年行关节镜下单纯盂唇修补术。B组16例,在2009年至2010年行关节镜下盂唇修补术加改良Remplissage术,采用双线锚钉将后方关节囊(非冈下肌腱)填充于肱骨头缺损处。两组患者术后采用相同方法进行康复训练。采用牛津肩关节不稳评分(OSIS)和ROWE评分进行疗效评估、对比术前和术后3个月、6个月、9个月及12个月时肩关节活动度。结果:所有患者均获得随访,A组随访平均(28.0±5.6)个月(20～38个月);术前、术后OSIS评分分别为(37.0±4.2)分(27～43分)和(18.0±3.3)分(12～25分),ROWE评分分别为(20.2±12.2)分(5～40分)和(83.8±7.3)分(70～95分);术后再脱位患者1例,由再次创伤造成,半脱位患者5例。B组随访平均(19.6±3.8)个月(14～27个月);术前、术后OSIS评分分别为(37.9±4.9)分(29～44分)和(13.4±2.1)分(12～20分),ROWE评分分别为(18.4±8.3)分(5～30分)和(95.3±5.3)分(80～100分);术后无再脱位患者。对两组患者术后肩关节活动度分别测量的结果显示,两组患者术后中立位外旋活动度恢复趋势无明显差异。Kaplan-Meier生存分析显示,两组患者术后不稳复发率差异有统计学意义(P=0.043)。结论:关节镜下盂唇修补合并改良Remplissage手术是治疗伴肱骨头中小型Hill-Sachs损伤的创伤性复发性肩关节前方不稳的有效方法,可显著提高肩关节稳定性,并对术后肩关节活动度无明显影响。     

A prospective outcome evaluation of arthroscopic Bankart repairs: minimum 2-year follow-up

BACKGROUND: Arthroscopic treatment of anterior shoulder dislocation has become possible through improvements in instruments and techniques. OBJECTIVE: To prospectively evaluate results of arthroscopic Bankart repairs at a minimum 2-year follow-up for patients with histories of shoulder dislocation and an anterior-inferior labral tear at the time of diagnostic arthroscopy. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A consecutive series of 85 patients (70 men, 15 women; mean age, 26 years) with Bankart lesions were treated with arthroscopic repair using suture anchors; 18 patients (27%) had extension of the labral injury into the superior labrum affecting some or all of the biceps anchor. Anchors were loaded with no. 2 nonabsorbable braided suture and placed 2 mm into the edge of the glenoid surface. A low anterior (5-o'clock) portal through the subscapularis tendon was used in all patients; 72 patients were evaluated at a minimum of 2 years postoperatively (mean, 46 months). RESULTS: Seven patients (10%) experienced recurrent instability after repair. Four patients had redislocations; 3 experienced recurrent subluxations. One patient had pain with the apprehension test without a clear history of recurrent instability. Of 18 collision athletes, 2 had dislocations at 22 and 60 months postoperatively. There were no complications, including no neurologic deficits. Clinical strength testing of the subscapularis muscle was normal in all patients. The mean Rowe score was 88 of 100 points, with 90% excellent or good results. Simple Shoulder Test responses improved from 66% positive preoperatively to 88% positive postoperatively. The American Shoulder and Elbow Surgeons scoring index averaged 92 of 100 points postoperatively. Pain analog scales improved from 5.5 preoperatively to 0.35 postoperatively on a 10-point scale. SF-12 scores improved for physical function. Patient satisfaction was rated 8.9 on a 10-point visual analog scale. CONCLUSION: Bankart repairs performed arthroscopically using properly implanted suture anchors and nonabsorbable sutures and in which associated pathoanatomy is addressed demonstrate low recurrence rates (10%) similar to historical open controls.     

Open Bankart repair with suture anchors for traumatic recurrent anterior shoulder instability: comparison of results between small and large Bankart lesions

This retrospective study was to demonstrate the clinical outcome of open Bankart repair with suture anchors for recurrent anterior shoulder instability, and to compare surgical results of small (<3 clock units) and large (>3 clock units) Bankart lesions. With an average follow-up of 55.6 months (2–8 years), there were 82 patients (60 right, 22 left shoulders) with the mean age of 27 years accepting open Bankart repair with suture anchors and capsular shift procedure by the same team. According to surgical findings, these patients were grouped into small (<3 clock units) and large (>3 clock units) Bankart lesions. Subjective outcomes were recorded according to the Bankart scoring system of Rowe. Rowe scores averaged 85.9±12.9 (range 25–100). The patients, 92–7 %, had objectively excellent or good results. Twenty nine patients (35.4%) had small Bankart lesions and 53 patients had large Bankart lesions. The Rowe scores in small Bankart lesions were better than that in large Bankart lesions (93.5±6.8 vs.81.8±13.6, Wilcoxon rank sum test, P<0.001). Mean scores of stability (Wilcoxon rank sum test, P=0.043), motion (Wilcoxon rank sum test, P=0.037), and function (Wilcoxon rank sum test, P<0.001) in small lesions also had superior outcomes than in large lesions. Four patients (4.9%) got fair results and two (2.4%) patients got poor results at the end of follow-up. The average loss of external rotation is 10°. Open Bankart repair with the aid of suture anchors still got satisfactory results in the treatment of traumatic recurrent anterior instability of the shoulder. The size of the Bankart lesion was a factor affecting surgical outcome. Small Bankart lesions usually got better results than large Bankart lesions.     

A prospective,randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute,traumatic, first-time shoulder dislocations

BACKGROUND: Nonoperative treatment of traumatic shoulder dislocations leads to a high rate of recurrent dislocations. HYPOTHESIS: Early arthroscopic treatment for shoulder dislocation will result in a lower recurrence rate than nonoperative treatment. STUDY DESIGN: Prospective, randomized clinical trial. METHODS: Two groups of patients were studied to compare nonoperative treatment with arthroscopic Bankart repair for acute, traumatic shoulder dislocations in young athletes. Fourteen nonoperatively treated patients underwent 4 weeks of immobilization followed by a supervised rehabilitation program. Ten operatively treated patients underwent arthroscopic Bankart repair with a bioabsorbable tack followed by the same rehabilitation protocol as the nonoperatively treated patients. The average follow-up was 36 months. RESULTS: Three patients were lost to follow-up. Twelve nonoperatively treated patients remained for follow-up. Nine of these (75%) developed recurrent instability. Six of the nine have required subsequent open Bankart repair for recurrent instability. Of the nine operatively treated patients available for follow-up, only one (11.1%) developed recurrent instability. CONCLUSIONS: Arthroscopic stabilization of traumatic, first-time anterior shoulder dislocations is an effective and safe treatment that significantly reduces the recurrence rate of shoulder dislocations in young athletes when compared with conventional, nonoperative treatment.     

Arthroscopic versus open Bankart repair for traumatic anterior shoulder instability

After more than 15 years of experience, arthroscopic shoulder stabilization is becoming less controversial. Historically, recurrence rates following arthroscopic stabilization have been higher than with open stabilization. Although a negligible advantage may exist in terms of expedited postoperative rehabilitation and improved postoperative recovery of motion, critics suggest that its use in contact athletes be limited. The indications for arthroscopic stabilization are expanding, in part, because of improved understanding of the pathophysiology of shoulder instability. Understanding the mechanism of recurrent instability following arthroscopic stabilization offers clues to how physicians can prevent unsatisfactory results in the future. With newer instrumentation and the ability to thermally treat capsular tissue, coexisting pathology, such as capsular plastic deformation, rotator interval lesions, and unrecognized intra-articular pathology, can now be addressed arthroscopically. The judicious use of these techniques is warranted until long-term study results become available. Ideal patients for arthroscopic Bankart repair have a discrete Bankart lesion; a robust, well-developed IGHL; no significant capsular laxity or intraligamentous injury; and an absence of concomitant intra-articular pathology. Additional findings on MR imaging or CT evidence of a discrete labral lesion and pure unidirectional anterior instability during EUA are also good prognostic indicators for arthroscopic Bankart repair. Arthroscopic criteria that render patients less appropriate for an arthroscopic repair include capsular injury, capsular laxity, a bony Bankart lesion, glenohumeral arthritis, and a rotator cuff tear. The authors' believe that either absent or patulous, poorly developed glenohumeral ligaments represent a poor prognostic indicator for a successful outcome following standard arthroscopic Bankart repair. Individuals with poor-quality tissue are more predictably managed using open capsulorrhaphy. Patients with pathologic ligamentous laxity in the absence of a Bankart lesion or any apparent intraligamentous injury to the IGHL are also good candidates for treatment with an open capsulorrhaphy. Findings determined from a thorough physical examination, EUA, and the pathology appreciated during diagnostic arthroscopy help to appropriately choose the surgical procedure that effectively addresses pathology in patients who present with recurrent traumatic anterior instability. Patient preferences and surgical experience are important determinants of procedure selection, and current arthroscopic techniques lack the versatility to uniformly address the entire spectrum of pathology that may be associated with traumatic anterior shoulder instability. Surgeons should always be prepared to convert to an open-stabilization technique if the arthroscopic technique is deficient in addressing all pathology identified at the time of surgery.     

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.     

A meta-analysis of open versus arthroscopic Bankart repair using suture anchors

Purpose of this study is to conduct a meta-analysis comparing the results of open and arthroscopic Bankart repair using suture anchors in recurrent traumatic anterior shoulder instability. Using Medline Pubmed, Cochrane and Embase databases we performed a search of all published articles. We included only studies that compared open and arthroscopic repair using suture anchors. Statistical analysis was performed using chi-square test. Six studies met the inclusion criteria. The total number of patients was 501, 234 suture anchors and 267 open. The rate of recurrent instability in the arthroscopic group was 6% versus 6.7% in the open group; rate of reoperation was 4.7% in the arthroscopic group vs. 6.6% in open (difference not statistically significant). The difference was statistically significant only in the studies after 2002 (2.9% of recurrence in the arthroscopic group vs. 9.2% in open; 2.2% of reoperation in the arthroscopic group vs. 9.2% in open). Results regarding function couldn’t be combined because of non-homogeneous scores reported in the original articles, but the arthroscopic treatment led to better functional results. Arthroscopic repair using suture anchors results in similar redislocation and reoperation rate compared to open Bankart repair; however, we need larger and more homogeneous prospective studies to confirm these findings.     

Arthroscopic anterior shoulder stabilization of collision and contact athletes

BACKGROUND: Repair of the anterior labrum (Bankart lesion) with tightening of the ligaments (capsulorrhaphy) is the recommended treatment for recurrent anterior glenohumeral dislocations. Current evidence suggests that arthroscopic anterior stabilization methods yield similar failure rates for resubluxation and redislocation when compared to open techniques. STUDY DESIGN: Case series; Level of evidence, 4 PURPOSE: To examine the results of arthroscopic anterior shoulder stabilization of high-demand collision and contact athletes. METHODS: Thirteen collision and 5 contact athletes were identified from the senior surgeon's case registry. Analysis was limited to patients younger than 20 years who were involved in collision (football) or contact (wrestling, soccer) athletics. Objective testing included preoperative and postoperative range of motion and stability. Outcome measures included the American Shoulder and Elbow Society shoulder score, Simple Shoulder Test, SF-36, and Rowe scores. The surgical procedure was performed in a consistent manner: suture anchor repair of the displaced labrum, capsulorrhaphy with suture placement supplemented with thermal treatment of the capsule when indicated, and occasional rotator interval closure. Average follow-up was 37 months (range, 24-66 months). RESULTS: Two of 18 contact and collision athletes (11%) experienced recurrent dislocations after the procedure; both were collision athletes. One returned to play 3 years of high school football but failed after diving into a pool. One patient failed in his second season after his stabilization (>2 years) when making a tackle. None of the contact athletes experienced a recurrent dislocation, with all of them returning to high school or college athletics. CONCLUSIONS: One hundred percent of all collision and contact athletes returned to organized high school or college sports. Fifteen percent of those collision athletes had a recurrence, which has not required treatment. Participation in collision and contact athletics is not a contraindication for arthroscopic anterior shoulder stabilization using suture anchors, proper suture placement, capsulorrhaphy, and occasional rotator interval plication.     

Open Bankart repair: correlation of results with postoperative subscapularis function

BACKGROUND: The potential weakness of the open Bankart procedure is the takedown and repair of the subscapularis tendon. It is not known to what extent this part of the procedure affects the final result. HYPOTHESIS: The function of the subscapularis muscle after surgery will be related to the patient's perception of surgical success. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 30 patients with traumatic anterior instability had an open Bankart repair by a single surgeon. These patients were observed for a mean of 4 years. At final follow-up, the patients filled out 3 self-assessment forms: the American Shoulder and Elbow Surgeons scale, the Western Ontario Shoulder Instability Index, and the Constant and Murley scale. An independent physician performed a complete physical examination. Strength testing of all muscle groups was performed and compared with the opposite normal side. RESULTS: Multiple factors were related to the patient's perception of the result. Only subscapularis function was found to have a statistically significant correlation. Of the patients, 23% had an incompetent subscapularis with a mean of 27% strength as compared with the opposite side. These patients had a positive lift-off test result and reported 57% good and excellent results; only 57% would have the surgery again. Of the patients, 77% had a normal functioning subscapularis with at least 80% strength as compared with the opposite side. These patients had a negative lift-off test result and had 91% good and excellent results; 100% would have the surgery again. The Western Ontario Shoulder Instability Index was the only scale that differentiated between a patient with subscapularis function and a patient without subscapularis function. CONCLUSION: Postoperative subscapularis function was the most critical factor in determining the patient's perception of surgical success. CLINICAL RELEVANCE: It is likely that handling of the subscapularis tendon during surgery and protection of the subscapularis in the first weeks after surgery are critical to the success of the open Bankart repair.