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.     

The Bankart lesion of the shoulder: A biomechanical analysis following repair

The Bankart lesion of the shoulder has long been associated with anterior instability. Our laboratory has developed a biomechanical model of the human shoulder which was used to determine the effects of creating a Bankart lesion on cadaveric specimens and then to compare the effects of two repair techniques. The model simulates the abducted, externally rotated position of the glenohumeral joint and uses pneumatic cylinders to simulate the rotator cuff forces. Specimens were tested intact following a partial Bankart lesion, following a complete Bankart lesion, and after performing a Bankart repair using three Mitek suture anchors. Finally, both the traditional and Mitek repairs were tested until failure. Strain in the inferior glenohumeral ligament (IGHL) and torque resistance was measured as an indication of instability of the joint. Strain was noted to decrease with increasing depth of lesion of the IGHL. Torsional rigidity of the shoulder decreased with increasing depth of lesion as well. Repairing the shoulder restores the strain and rigidity to control conditions. The mean load until failure was greater with the traditional repair than with the suture anchor technique. This study quantitates the effects of a Bankart lesion of the shoulder, and demonstrates that repairing the lesion with a suture anchor technique restores the biomechanics of the shoulder.Investigation performed at the Albert B. Ferguson, Jr., MD Laboratory for Orthopaedic Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USAThis work was supported by a grant from the Whitaker Foundation     

关节镜下Bankart修复治疗训练伤所致慢性肩关节前方不稳

目的观察关节镜下Bankart修复治疗训练伤所致慢性肩关节前方不稳的临床疗效。方法选择21例肩关节前方不稳的患者,关节镜下锚钉修复盂唇损伤,同时修复合并出现的上盂唇前后(SLAP)损伤,较大的Hill-sachs损伤。采用UCLA功能评分标准和SST评分进行疗效的评估,记录术前和终末随访的得分。结果术后患者随访12~45个月,平均随访27个月。SST得分术前为(6.72±2.38)分,术后终末随访评分为(11.24±1.46)分,同术前比较差异有统计学意义(P<0.01)。术前UCLA平均得分为(19.55±5.02)分,术后终末随访评分为(33.19±4.61)分,与术前比较差异有统计学意义(P<0.01)。结论关节镜下Bankart修复治疗训练伤所致肩关节前方不稳疗效满意,可以很好恢复肩关节功能。     

Effects of posterior-inferior capsular plications in range of motion in arthroscopic anterior bankart repair: a prospective randomized clinical study

The effects of posterior plications associated with anterior shoulder instability surgery are still unclear both on shoulder range of motion (ROM) and on recurrence rate. The objective of this randomized study is to evaluate the influence of posterior-inferior plications, performed in association with repair of anterior Bankart lesion, on gleno-humeral (GH) range of motion. In a 24-month period, 40 patients were prospectively enrolled in this study. The criteria for inclusion were age between 17 and 40 years, traumatic unidirectional instability, no previous shoulder surgery, no more than three episodes of dislocation, no relevant glenoid bone deficiency, no clinical evidence of pathological anterior inferior laxity (measured with external rotation with the arm at the side inferior to 90° and Gagey sign negative) and arthroscopic finding of isolated anterior Bankart lesion. A total of 20 patients (group A) were randomized to treat Bankart lesion using three bioadsorbable anchors loaded with a #2 braided polyester suture. In 20 randomized patients (group B) two posterior-inferior capsular plications performed with a #1 polidioxanone suture without any capsular shift were added to the same anterior capsulorraphy performed in group A. Postoperative rehabilitation protocol was the same for all 40 patients. Patients were examined preoperatively and at a 2-year follow-up by a single independent expert physician unaware of the surgical procedure. GH ROM, Constant, UCLA and ASES rating scores as well as recurrence of instability were recorded. At follow-up, forward flexion (FF) decreased by a mean value of 14.5° (median −10°; range −5° to −35°; P < 0.001) in group B and increased by a mean value of 3.5° (median 0°; range −25° to 40°; P < 0.312) in group A; external rotation with arm adducted (ER1) increased by a mean value of 1.8° (median 0°; range −15°to 30°; P < 0.924) in group B, and increased by a mean value of 2.6° (median 2.5°; range −38° to 40°; P < 0.610) in group A; external rotation with arm abducted at 90° (ER2) decreased by a mean value of 2.9° (median 0°; range: −20° to 10°; P < 0.161) in group B and increased by a mean value of 0.7° (median 0°; range −30° to 25°; P < 0.837) in group A; the IR2 decreased by a mean value of 2.4° (median −3.5°; range −15° to 10°; P < 0.167) in group B and increased by a mean value of 2.2° (median 0°; range −20° to 30°; P < 0.456) in group A. The UCLA mean score gains by 43.1% (median 40; P < 0.001) relatively, and of 45.2% relatively (median 40; P < 0.001), respectively, in group B and A, ASES mean score relatively gains by 21.7% (median 21.2%; P < 0.001) in group B, and of 19.2% (median 18.9%; P < 0.001) in group A, and Constant mean score improves by 20.2% (median 16.5; P < 0.001) in group B, and 10.2% (median 8.4%; P < 0.001) in group A. Thus, the only statistical significant differences were the reduction of forward flexion in group B and the improvements of the scores in both groups. No recurrence of instability was found in the plicated group, while in the non-plicated group we had one traumatic recurrence. In conclusion, arthroscopic posterior-inferior plications associated with a Bankart lesion repair in a selected group of patients seem to reduce only FF, without any effect on rotation. A longer follow-up and a larger number of patients are needed to give definitive conclusions on the benefit to the recurrence rate.     

Arthroscopic bankart repair with the suretac device for traumatic anterior shoulder instability in athletes

Arthroscopic treatment of anterior shoulder instability in the athlete has evolved tremendously over the past decade. Currently, most techniques include the use of suture and suture anchors. However, the variety of arthroscopic instruments and techniques that are available shows the complexity of intra-articular tissue fixation, which includes anchor placement, suture passing, and knot tying. Stabilization using the Suretac device (Acufex Microsurgical, Mansfield, MA) simplifies tissue fixation by eliminating the need for arthroscopic suture passing and intraarticular knot tying. However, a successful outcome is highly dependent on accurate patient selection. Preoperative evaluation, examination under anesthesia, and the pathoanatomy defined by a thorough arthroscopic examination suggest the most effective treatment strategy. The ideal candidate for shoulder stabilization using the Suretac device is an athlete with a relatively pure traumatic anterior instability pattern with detachment pathology (eg, a Bankart lesion) and minimal capsular deformation.     

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.     

Sports ability after Bankart procedure in professional athletes

Recurrent anterior shoulder instability and the restoration of sports ability after surgery are common problems, especially among professional athletes. The purpose of this study was to evaluate the rate, level and time of returning to sports activity after Bankart procedure in anterior shoulder instability in high level atheletes. From 1992–1994 61 patients suffering from recurrent anterior shoulder instability were operated on open Bankart procedure. 44 out of 61 were professional athletes. There were 7 handball, 7 basketball, 6 football, 2 waterpolo and 1 base-ball player and 4 wrestlers, 2 weightlifters, 2 boxers, 3 bicyclists, 2 motorists, 2 swimmers, 2 sailors, 2 kayakers and 2 skiers. The mean duration of instability was 19.1 months (3–72) before operation. 29 patients had posttraumatic recurrent anterior dislocation and 15 patients had posttraumatic anterior subluxations. The average number of redislocations was 4.4, ranging from 2 to 11. At the follow-up examination the patients were tested clinically for instability using the special score created by Walch and Duplay and the Constant functional score. We measured the strength of the rotator cuff by Kintrex isokinetic device from the 10th postoperative week. 35 out of 44 professional athletes could be fellowed-up. The average follow-up period was 14.2 months, from 6 to 31. 88% of the patients were able to return to sports participation, 66% on the previous levels and 22% on a lower level. 12% of the patients finished their professional sports career. The mean rehabilitation period was 5.8 months, the average period of full restoration of sports ability was 9.3 months. Similar results were documented with the Constant score and the Walch-Duplay test (88% excellent or good, 12% fair). The main reason for the inability to continue sports activity was some pain during extreme abduction and extrnal rotation of the arm and recurrent sensations of subluxation (3 cases). Based on the results of the follow-up examinations an early diagnosis is paramount followed by timely surgical intervention to restore anatomical integrity in proven cases of shoulder instability in professional athletes. The open Bankart procedure is preferred giving excellent functional results and providing good chances for the atheletes to return to their previous sports level.     

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

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

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.     

A new technique to improve tissue grip and contact force in arthroscopic capsulolabral repair: the MIBA stitch

The success of anatomic repair of Bankart lesion diminishes in the presence of a capsule stretching and/or attenuation is reported in a variable percentage of patients with a chronic gleno-humeral instability. We introduce a new arthroscopic stitch, the MIBA stitch, designed with a twofold aim: to improve tissue grip to reduce the risk of soft tissue tear, particularly cutting through capsular–labral tissue, to and address capsule-labral detachment and capsular attenuation using a double loaded suture anchor. This stitch is a combination of horizontal mattress stitch passing through the capsular–labral complex in a “south-to-north” direction and an overlapping single vertical suture passing through the capsule and labrum in a “east-to-west” direction. The mattress stitch is tied before the vertical stitch in order to reinforce the simple vertical stitch, improving grip and contact force between capsular–labral tissue and glenoid bone.     

Absorbable implants for open shoulder stabilization

Eighteen consecutive patients who had recurrent, unidirectional, post-traumatic shoulder instability were included. All these patients underwent surgery using an open Bankart technique involving absorbable suture anchors. The median age at the index operation was 27 (16–50) years. One subluxation and two re-dislocations occurred during the follow-up period of 90 (80–95) months. At the 90-month control, the Rowe and Constant scores were 94 (63–100) points and 88.5 (65–100) points, respectively. The strength measurements on the index side in 90° abduction revealed 8.1 (3.7–17.2) kg compared with 7.6 (2.7–17.6) kg on the contra lateral side (n.s.). The external rotation in abduction was 80 (60–95)° compared with 100 (70–120)° for the contra lateral side (p = 0.0015). Signs of minor or moderate degeneration were found in five of 18 patients (28%) on the preoperative radiographs. There was a significant continuous increase in degenerative changes during the follow-up period as seen on the seven, 33 and 90-month radiographs (p = 0.01, 0.03 and 0.01, respectively). On the 90-month radiographs, 12 of 18 patients (67%) had minor, moderate or severe degenerative changes (p = 0.0004 preoperative vs. 90 months). On the 7-month radiographs, two of 18 patients (11%) had invisible or hardly visible drill holes in conjunction with the absorbable implants. On the 90-month radiographs, 12 of 18 patients (67%) had invisible or hardly visible drill holes (p = 0.003 7 months vs. 90 months). In the long term, the method resulted in stable, well-functioning shoulders in 15 of 18 patients (83%). The stabilisation was not, however, able to prevent further increases in radiographic degenerative changes during the 7–8-year follow-up. The drill holes used for the absorbable suture anchors appeared to heal in the majority of patients during the follow-up period.     

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

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

Comparative study of direct MR arthrography and CT arthrography with arthroscopic correlation in preoperative evaluation of anterior shoulder instability

Purpose

To compare direct MR arthrography and CT arthrography for the preoperative planning of shoulder anterior instability.

Patients and methods

47 patients were included in this study. 43 patients with clinical history of anterior GHI or recurrent shoulder pain had no clinical findings of rotator cuff abnormality. They experienced multiple anterior dislocations of the shoulder. No patient showed evidence of multidirectional instability or generalized ligamentous laxity. The remaining 4 patients complained of anterior shoulder instability after anchor repair. All the patients underwent direct CT and MR arthrography. The results of CTA and MRA were compared with results obtained from arthroscopy in each patient to detect the sensitivity and specificity of each modality.

Results

The sensitivity and specificity of CTA for bankart lesion are 89.4% and 96.4% respectively and of MRA 94.7% and 96.4%, for Perthes lesion the sensitivity and specificity of CTA are 33.3% and 100% respectively and of MRA 66.6% and 100%, for ALPSA the sensitivity and specificity of CTA are 85.7% and 97.5% respectively and of MRA 100% and 97.5%, for GLAD the sensitivity and specificity of CTA are 80% and 97.6% respectively and of MRA 60% and 97.6%, for SLAP lesion the sensitivity and specificity of CTA are 100% and 100% respectively and of MRA 100% and 100%, for absent or degenerated labrum the sensitivity and specificity of CTA are 100% and 100% respectively and of MRA 66.6% and 97.7%, for post operative recurrent Bankart lesion the sensitivity and specificity of CTA are 100% and 100% respectively and of MRA 50% and 100%, for bony glenoid fracture the sensitivity and specificity of CTA are 100% and 100% respectively and of MRA 66.6% and 97.5%.

Conclusion

CTA and MRA were equivalent in demonstrating labro-ligamentous and cartilaginous lesions associated with shoulder instability. CTA was superior in detecting post operative instability and glenoid rim osseous lesions that are known to be a decisional element in the surgical strategy. Hence, CTA may be considered a method of choice in the preoperative evaluation of shoulder anterior instability.     

Isolated HAGL lesion after arthroscopic Bankart repair in a professional soccer player

Post-traumatic anterior shoulder instability commonly occurs following an avulsion of capsulolabral complex from glenoid (Bankart lesion) or rarely after humeral avulsion of the glenohumeral ligaments (HAGL lesion). Arthroscopic Bankart repair offers high success rates of healing. However, trauma following the treatment may cause implant failure or re-avulsion of the treated tissue. We aim to present the diagnosis and treatment of an isolated HAGL lesion in a professional soccer player who had previously undergone arthroscopic Bankart repair.     

Traumatic anterior shoulder instability in the athlete

Anterior glenohumeral dislocation is common among athletes and may progress to recurrent instability. The pathoanatomy of instability and specific needs of each individual should be considered to prevent unnecessary absence from sport. Traditionally, primary dislocations have been managed with immobilization followed by rehabilitation exercises and a return to sporting activity. However, arthroscopic stabilization and external rotation bracing are increasingly used to prevent recurrent instability. In addition to the typical capsulolabral disruptions seen following a primary dislocation, patients with recurrent instability often have coexistent osseous injury to the humeral head and glenoid. In patients without significant bone loss, open soft‐tissue stabilizations have long been considered the ‘gold standard treatment’ for recurrent instability, but with advances in technology, arthroscopic procedures have gained popularity. However, enthusiasm for arthroscopic repair has not been supported with evidence, and there is currently no consensus for treatment. In patients with greater bone loss, soft‐tissue stabilization alone is insufficient to treat recurrent instability and open repair or bone augmentation should be considered. We explore the recent advances in epidemiology, classification, pathoanatomy and clinical assessment of young athletes with anterior shoulder instability, and compare the relative merits and outcomes of the different forms of treatment.