Editorial Commentary: Hyperlaxity Is a Common Factor in Failed Arthroscopic Bankart Repair

Hyperlaxity is a common factor in failed arthroscopic Bankart repair. The best treatment for patients with instability, hyperlaxity, and minimal bone loss is still controversial. Patients with hyperlaxity often have subluxations rather than frank dislocation, and concurrent traumatic structural lesions are infrequent. Conventional arthroscopic Bankart repair with or without capsular shift poses a risk of recurrence because of soft tissue insufficiency. The Latarjet is not a good procedure in patients with hyperlaxity and instability, especially an inferior component, and risks include a higher degree of postoperative osteolysis after Latarjet with an intact glenoid. The arthroscopic Trillat procedure may be used to treat this challenging patient group by repositioning the coracoid medially and downward by a partial wedge osteotomy. The coracohumeral distance and shoulder arch angle are decreased after performing the Trillat, which may reduce instability, and the Trillat procedure mimics the sling effect of the Latarjet. However, complications should be considered due to the procedure's nonanatomic nature, such as osteoarthritis, subcoracoid impingement, and loss of motion. Other options to improve inferior stability include robust rotator interval closure, coracohumeral ligament reconstruction, and posteroinferior/inferior/anteroinferior capsular shift. The addition of posteroinferior capsular shift and rotator interval closure in the medial lateral direction also benefits this vulnerable patient group.     

Editorial Commentary: Middle-Age Does Not Confer Immunity From Recurrent Instability After Arthroscopic Bankart Repair

Recurrent anterior shoulder instability remains a challenge to treat with arthroscopy, as the rate of postoperative instability remains high in certain patient populations. Indications for performing an “anatomic” arthroscopic reconstruction (isolated Bankart repair) are narrowing as surgeons identify risk factors for failure with this approach. In particular, the presence of certain bone loss patterns that occur with high numbers of instability events should prompt consideration for nonanatomic reconstruction, such as Latarjet or Hill-Sachs remplissage, to reduce the rate of postoperative recurrent instability.     

Editorial Commentary: Shoulder Remplissage Is a Beneficial Addition to Bankart or Glenoid Bone Loss Treatment: Stay on Track and Use Wisely

In patients with on-track shoulder Hill–Sachs lesions, the addition of remplissage using a double-pulley technique to Bankart repair improves outcomes including residual apprehension and without loss of external rotation. A caveat is that measurement of both the Hill–Sachs lesion and glenoid bone loss may be inconsistent. A second caveat is that determination of the glenoid track can be affected by scapular positioning. Not all “on-track” lesions are alike. In terms of outcome assessment, apprehension has up to 95% specificity for anterior shoulder instability and is a key finding in determining the results of shoulder stabilization. Recurrent instability may not be as sensitive of an outcome measure, because patients will avoid positions of apprehension. Finally, remplissage should be used cautiously in peripheral track lesions. For smaller Hill–Sachs lesions, remplissage can provide extraordinary success, and for larger lesions that are close to engaging, glenoid bone loss must also be treated, especially in a younger, active patient.     

Editorial Commentary: Shoulder Arthroscopic Dynamic Anterior Stabilization Is Effective for Anteroinferior Shoulder Instability With Limited Anterior Bone Loss

Shoulder dynamic anterior stabilization (DAS) is an efficient and well-established glenohumeral stabilization technique, offering an arthroscopic alternative to Latarjet and glenoid reconstruction with distal tibial allograft or the iliac crest autograft. DAS is essentially an augmented Bankart procedure and can be performed using transfer of either the long head of the biceps tendon or the conjoined tendon. Both result in similar and acceptable rates of recurrences, complications, return to sport, and subjective shoulder function. However, the effectiveness of Bankart repair on shoulder stability decreases significantly over time, so long-term follow-up evaluations of DAS are required. The best indication for DAS may be anteroinferior shoulder instability with limited anterior bone loss.     

Editorial Commentary: Shoulder Glenoid Suture Anchor Insertion Depth: The Tip of an Iceberg

The term “translational research” means that the results of a bench-top analysis could quickly be applied, or translated, to the clinical setting. Nevertheless, cadaveric analysis is applicable primarily to the conditions tested. Care should be taken to consider that when it comes to investigation of shoulder glenoid suture anchor insertion, there are many variables and outcome measures to consider.     

Editorial Commentary: Rate of Shoulder Instability,and Outcome After Arthroscopic Bankart Stabilization,Are Equal Among Men and Women When Similar Sports Are Compared

Male athletes have been shown to have a higher incidence of shoulder instability and higher rates of recurrence after arthroscopic stabilization. However, when similar sports are compared, the incidence of instability effectively equalizes. When similar sports are compared, outcomes after arthroscopic Bankart repair may also equalize when compared by sex. Next, contact and collision athletes with shoulder instability have more severe intra-articular pathologies that affect their treatment and outcomes. As these sports become more available to women worldwide, we may see more women athletes with more complex shoulder instability-related pathology. Ultimately, the solution may be to ensure equal resources available to optimize surgical outcomes for athletes after surgery, regardless of sex. We must not leave female athletes on the bench.     

Editorial Commentary: Dynamic Anterior Stabilization via Biceps Tenodesis to the Glenoid Is an Option for Anterior Shoulder Instability With Subcritical Glenoid Bone Loss

A nuanced approach to treatment of anterior shoulder instability is encouraged, particularly in patients with subcritical glenoid bone loss. In patients with bone loss, recurrent instability after isolated arthroscopic Bankart repair has dampened enthusiasm for this procedure. Adjunctive treatment with remplissage or dynamic anterior stabilization via biceps tenodesis to the glenoid is an alternative to bone transfer procedures, which are effective but have higher complication rates. Dynamic anterior stabilization or tenodesis of the long head of the biceps to the 3-o’clock position on the glenoid through a subscapularis split is biomechanically superior to isolated Bankart repair for reducing anterior translation, even in the setting of minor glenoid bone loss due to a sling effect similar to that produced by the Latarjet procedure. A disadvantage is placement of a large implant into the small space of the anterior glenoid and creation of a soft-tissue defect in the capsule.     

Editorial Commentary: Causes of Failure After Arthroscopic Rotator Cuff Repair

Causes of failure after arthroscopic rotator cuff repair include patient factors, tear factors, and surgical factors. Failure may occur at the suture–tendon interface, the bone–tendon interface, or the bone–anchor interface. Low bone mineral density (BMD) in the greater tuberosity has been reported as a prognostic factor for recurrent tears following rotator cuff repair, and although most studies suggest the tendon-to-suture interface as the “weakest link,” patients with low BMD may have lower suture anchor pull-out strength. A potential alternative cause of failure is the suture cutting through the greater tuberosity bone in patients with low BMD. Knotless suture bridge constructs or single-row constructs may be more susceptible to a suture cutting through the bone. The knotted suture bridge technique, wherein the medial mattress sutures are tied, may to some extent “shield” against complete cut-through. When bone quality appears poor, a common response is to change the type of anchor, size of anchor, or the location of the anchor. Other factors, such as bone preparation, suture type, suture tensioning, and anchor type (e.g., internal vs external locking), may all potentially affect suture cutting through weak bone.     

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

The recurrence of shoulder instability is a challenging complication after anterior open or arthroscopic stabilization in patients with glenohumeral instability. Use of the arthroscopic Bankart procedure has increased over the last decade, because of its less invasiveness and low complication rates compared with the Latarjet procedure. However, arthroscopic repair has the possibility of a greater recurrent instability rate. The Instability Shoulder Index Score (ISIS) has been developed to predict the success of isolated arthroscopic Bankart repair for the management of recurrent anterior shoulder instability. The risk factors associated with the recurrence of instability are age, level and type of sports participation, shoulder hyperlaxity, and humeral and glenoid bony lesions. The ISIS is a validated tool to predict the recurrence of dislocation after arthroscopic surgery in patients with shoulder instability. The arthroscopic Bankart procedure can be performed in patients with ISIS ≤3 with a low risk of recurrence of glenohumeral instability. The Latarjet procedure should be recommended in patients with ISIS >6. The management of patients with ISIS between 4 and 6 is still controversial and ranges from arthroscopic Bankart procedure with the addition of remplissage to the Latarjet procedure. Because advanced imaging techniques, such as computed tomography scans, allow us to assess appropriately the glenoid and humeral bone defect, their use is recommended in addition to ISIS.     

Editorial Commentary: Glenoid Reconstruction With Autologous Tricortical Iliac Crest Represents an Alternative to Bankart Repair and Remplissage for Anterior Shoulder Instability With Subcritical Bone Loss

Traumatic anterior shoulder dislocations are estimated to occur in approximately 2% of the population, frequently with concomitant anterior-inferior labral tears and associated Hill-Sachs lesions of the humeral head. So-called bipolar (or engaging) lesions with attritional bone loss may be exacerbated by recurrent instability, in terms of both prevalence and severity. The glenoid track concept and distance to dislocation have offered context for evaluating bipolar lesions, and increasingly, options for bone block reconstruction are considered for definitive treatment. Recently, concerns have been raised regarding coracoid transfer or Latarjet treatment, particularly with screw constructs in which catastrophic failure, hardware breakage, and secondary arthritis may develop. The Eden-Hybinette procedure, or tricortical iliac crest autograft bone augmentation, may represent a promising alternative to existing options while also restoring native glenoid bone stock. Additionally, suture button fixation may obviate the traditional pitfalls of prior bone block procedures while also achieving reproducible functional outcomes and low rates of recurrence. However, this must be considered alongside other contemporary arthroscopic treatments, such as combined arthroscopic Bankart repair and remplissage.     

Arthroscopic Shoulder Stabilization: Is There Ever a Need to Open?

Recent studies show comparable results of arthroscopic shoulder stabilization techniques compared with the gold standard open Bankart reconstruction. Great technical advances and ever-increasing surgeon experience have rendered pathology once deemed an indication for open surgery as treatable by arthroscopic means. With this movement toward a more universal application of all-arthroscopic techniques, we might consider the following question: Is there ever a need to open? To answer this question, we must first consider normal anatomy and then appreciate the contribution of deranged pathoanatomy to recurrent instability in each individual case. The surgeon must then determine whether this is best addressed via an arthroscopic or open technique. Arthroscopy, as compared with open stabilization procedures, holds the potential benefits of decreased morbidity rates, early functional rehabilitation, and improved range of motion. Despite potential advantages, arthroscopic stabilization is clearly contraindicated when a significant pathologic lesion contributing to recurrent instability cannot be adequately addressed as a result of the limitations of current techniques or instrumentation. On the basis of this principle, we believe that sizable glenohumeral bone defects remain the only absolute contraindication to an all-arthroscopic approach. Many complicating issues, such as attenuated capsule, humeral avulsion of the glenohumeral ligament lesions, cases of revision surgery, and collision or contact athletes, exist and warrant close attention. We prefer to think of these situations as “challenges” for which both arthroscopic and open surgery should be considered, rather than as true contraindications to arthroscopic shoulder stabilization. We are, by no means, advocating arthroscopic treatment in all cases of shoulder instability, because this would represent a gross oversimplification of the issues at hand. However, we do acknowledge that the steadfast contraindications to arthroscopic shoulder stabilization are decreasing every day.