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Arthroscopic Shoulder Stabilization With Suture Anchors: Technique, Technology, and Pitfalls
Abstract
Arthroscopic treatment of anterior shoulder instability has evolved significantly during the past decade. Currently, most techniques include the use of suture and suture anchors. A successful outcome is highly dependent on accurate patient selection. Preoperative evaluation, examination with the patient under anesthesia, and defining the pathoanatomy by a thorough arthroscopic examination determine the most effective treatment strategy. Technical skills include the surgeon's ability to accomplish anchor placement, suture passage, and arthroscopic knot tying. Various instruments and techniques are available to facilitate arthroscopic reconstruction. In properly selected patients and with good surgical technique, outcomes should approximate or exceed traditional open stabilization techniques.
... 9 Among these, suture anchors are the most widely used device with favourable long-term outcomes. 10,11 Suture anchors, whether traditional (knotted) or knotless, should be placed in an adequate number at the appropriate angle and place. Capsulolabral fixation to the glenoid based on the use of three anchors placed at distinct points has been recommended. ...
... Capsulolabral fixation to the glenoid based on the use of three anchors placed at distinct points has been recommended. 10,12 These multiple points of fixation, opposite the inserted anchors, maintain the labral tissues in contact with the glenoid until healing occurs. The use of knotless anchors obviates the need for knot tying; this has proved to be a fast technique for secured labral fixation and will be the basis for the present article. ...
... The BioKnotless is an absorbable KSA composed of PLLA, whereas the PushLock is a permanent type composed of PEEK. 10 When comparing the mechanical strength, Peters and colleagues reported a significantly higher rate of re-dislocation and prolonged impairments in mobility and function when using an absorbable KSA compared to the permanent counterpart. 27 In a biomechanical study by Khoo and colleagues, the authors demonstrated a significantly weaker BioKnotless repair when compared to repairs with other three anchor systems, including the PushLock. ...
Aim
The aim of this study was to compare the clinical outcomes of arthroscopic Bankart repair (ABR) using two types of knotless suture anchors (KSAs) in patients with post-traumatic recurrent anterior glenohumeral instability (AGHI).
Methods
Thirty-two patients underwent an ABR using KSAs: a permanent KSA (PushLock) and an absorbable counterpart (BioKnotless). There were 16 patients in each group. Pre-and post-operative assessment for shoulder function using the American Shoulder and Elbow Surgeons and Constant–Murley scores, recurrence of instability, post-operative limitation of external rotation (ER) and ability to return to pre-injury level were recorded in both groups.
Results
Both groups displayed significant improvements in functional scores ( p < 0.0001) without a significant difference between the groups. Of the 32 patients, 9.4% had recurrence of instability (one re-dislocation in group 1 and two symptomatic subluxations in group 2). Return to pre-injury level occurred in 87.5% and 81.3% of group 1 and group 2, respectively. There was 2° to 3° loss of ER after ABR in both groups; the difference between the groups was not significant ( p = 0.45).
Conclusion
ABR for recurrent AGHI using a permanent or absorbable KSA offers comparable successful outcomes; no significant statistical difference was found.
... This choice involves considering the size and material of the anchor, which may vary from metallic to bioabsorbable, depending on the patient's condition and the specific surgical requirements. Moreover, the insertion technique is paramount [17]. The insertion process involves loading the suture into the anchor implant, placing it into a predrilled bone hole, and then applying tension by pulling on the free suture ends. ...
... (b, d) postoperative images, present no foreign body shadow for precise placement, especially in less accessible surgical areas. Additionally, the use of ergonomic instruments designed for anchor insertion can improve the surgeon's control and accuracy during the procedure [17,20,21]. However, the use of suture anchors is not without its disadvantages. ...
Background
While suture anchors are widely used in medical procedures for their advantages, they can sometimes lead to complications, including anchor prolapse. This article presents a unique case of suture anchor prolapse at the base of the distal phalanx of the little finger after extensor tendon rupture reconstruction surgery.
Case presentation
A 35-year-old male, underwent extensor tendon rupture reconstruction using a non-absorbable suture anchor. After seven years the patient visited our outpatients complaining of stiffness, pain, and protrusion at the surgical site. Initial X-ray imaging suggested suggesting either a fracture of the distal phalanx or tendon adhesion but lacked a definitive diagnosis. Subsequent magnetic resonance imaging (MRI) revealed bone connectivity between the middle and distal phalanges with irregular signal shadow and unclear boundaries while maintaining a regular finger shape. MRI proved superior in diagnosing prolapsed suture anchors, marking the first reported case of its kind. Surgical intervention confirmed MRI findings.
Conclusions
Suture anchor complications, such as prolapse, are a concern in medical practice. This case underscores the significance of MRI for accurate diagnosis and the importance of tailored surgical management in addressing this uncommon complication.
... Historically, open repair was the procedure of choice due to early data which demonstrated decrease recurrence rates; however, as surgeons have become more facile at arthroscopy and there has been an improvement in both instrumentation and surgeon repair techniques, this belief has been disproved. [30][31][32][33] Given these recent findings, arthroscopic stabilization has increased dramatically, as it has the advantages of decreased pain, improved postoperative range of motion and faster rehabilitation allowing expeditious RTP. [32][33][34] More recent data has demonstrated low recurrence rates following arthroscopic Bankart repair with recurrence rates as low as 5% and RTP rates exceeding 90%. ...
... [30][31][32][33] Given these recent findings, arthroscopic stabilization has increased dramatically, as it has the advantages of decreased pain, improved postoperative range of motion and faster rehabilitation allowing expeditious RTP. [32][33][34] More recent data has demonstrated low recurrence rates following arthroscopic Bankart repair with recurrence rates as low as 5% and RTP rates exceeding 90%. [35][36][37] Despite this data, it is imperative to consider patient selection, as open Bankart repair may be favorable in a select cohort of patients who are at increased risk for recurrent instability after arthroscopic repair. ...
Management of in-season anterior instability poses a unique challenge to providers as they are faced with the conundrum of helping an athlete return to play as quickly as possible, while minimizing the risk of recurrent instability and progressive damage to the glenohumeral joint. The decision for early return to play versus in-season surgery ultimately is a collective decision-making process between the athlete, provider and training staff. However, it is the physician's obligation to properly counsel the athlete on the risks of early return to play following conservative management. Apart from athletes who are in the last season of their career or have other extenuating circumstances, requiring return to play (RTP) in the same season (i.e. upcoming championship or combine), given the high risk of recurrence in athletes managed conservatively, physicians should strongly encourage early surgical stabilization. Surgical management of instability most commonly includes arthroscopic Bankart repair and capsulorrhaphy, however open Bankart repair should be considered in high-risk athletes (i.e. contact athletes, recurrent instability, sub-critical glenoid bone loss). In athletes with critical glenoid bone loss an osseous augmentation procedure should be performed, such as the Latarjet procedure.
... In the setting of associated osseous defects, 73% of surgeons recommended the Latarjet procedure in patients with glenoid bone loss, and 60% of surgeons recommended remplissage for an engaging Hill-Sachs lesion 53 . Potential explanations for the substantial advances in arthroscopic shoulder stabilization techniques are improved instrumentation (e.g., suture anchors), greater surgeon experience using the arthroscope, improved recognition of glenoid and humeral head bone loss, improved patient selection, and improved repair techniques, such as the use of multiple suture anchors and extending repairs posteroinferiorly [55][56][57][58] . ...
... Arthroscopic stabilization with a Bankart repair is an appealing treatment modality for primary and recurrent anterior shoulder instability without glenoid bone loss in athletes. The advantages of arthroscopic repair compared with open repair include decreased pain, improved postoperative range of motion, and a quicker rehabilitation time, promoting a fast return to play 29, 54,56,57 . However, open Bankart repair may be more effective and favored over arthroscopic repair under certain circumstances. ...
» Anterior shoulder dislocation is a common problem in athletes and has serious implications due to the rate of injury recurrence and the resulting extended time out of play.
» There are a variety of management options that address shoulder instability in an in-season athlete, and the decision-making approach should be individualized to the athlete.
» Although nonoperative management and return to play in the same season may be a suitable option for a subset of athletes who wish to return to play as soon as possible (during a recruiting season, for an upcoming Combine, or if they are in the last season of their career), given the high risk of recurrence, we recommend that immediate surgical intervention should be considered to decrease the risk of further damage to the glenohumeral joint.
» Arthroscopic stabilization currently is the most commonly performed intervention for athletes with anterior shoulder instability in the United States, but open repair remains an excellent option for high-risk patients.
» In collision athletes with subcritical glenoid bone loss between 13.5% and 25%, early open anterior capsulolabral reconstruction or a Latarjet procedure is recommended. If glenoid bone loss exceeds 25%, the Latarjet or another glenoid osseous augmentation procedure should be performed to reduce the risk of recurrent anterior instability.
... Ðåöèäèâû áûëè çàôèêñèðîâàíû âñåãî â 4% ñëó÷àåâ. B.J. Cole è A.A. Romeo [39] â òå÷åíèå 2 ëåò íàáëþäàëè 45 ïàöèåíòîâ-ñïîðòñìåíîâ, îïåðèðîâàííûõ òàêaeå ñ ïîìîùüþ ÿêîðíûõ ôèêñàòîðîâ. Èìè áûëî ïîëó÷åíî 96% õîðîøèõ è îòëè÷íûõ ðåçóëüòàòîâ. ...
... Ó ýòîé ãðóïïû ïàöèåíòîâ ìû èçó÷àëè ñâîéñòâà ãëåíîèäà ëîïàòêè, èçìåíåíèå êîòîðûõ ñïîñîáíî ïîâëèÿòü íà ñòàáèëüíîñòü ïëå÷åâîãî ñóñòàâà, à èìåííî ðàçìåðû ãëåíîèäà (âûñîòà, øèðèíà, ïëîùàäü), ïîâîðîò (àíòåâåðñèÿ, ðåòðîâåðñèÿ) è óãîë íàêëîíà [60]. Çà îñíîâó èçó÷åíèÿ âûøåóêàçàííûõ ïðèçíàêîâ áûëè âçÿòû ñòàòèñòè÷åñêèå äàííûå ïàðàìåòðîâ ãëåíîèäà ëîïàòêè ÷åëîâåêà, ãäå ñðåäíÿÿ âûñîòà ãëåíîèäà (glenoid height) íà îñíîâàíèè ðàçëè÷íûõ èññëåäîâàíèé [61] áûëà îïðåäåëåíà êàê 38 (33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45) ìì äëÿ ìóae÷èí è 36,2 (32,0-43,0) ìì -äëÿ aeåíùèí. Øèðèíà ãëåíîèäà (glenoid width) ðàâíÿëàñü 28,3 (24,0-32,0) ìì äëÿ ìóae÷èí è 23,6 (17,0-27,0) ììäëÿ aeåíùèí ñîîòâåòñòâåííî. ...
An analysis of literature data was conducted to characterize the main current stage of development and formation of diagnosis and treatment of shoulder instability. The purpose of this review was to determine the main directions in the treatment of recurrent shoulder instability and problematic issues that require further scientific research. The main results of patients monitoring that were undergone different types of arthroscopic treatment were presented. The present level of diagnostics allows to accurately define the indications for surgical treatment. A method of glenoid bone defect reconstruction is presented that based on careful preoperative planning. Determination of possible risk factors and every possible pathogenesis link and individual preoperative planning are the main tasks in the prevention of the shoulder instability recurrences.
... Ðåöèäèâû áûëè çàôèêñèðîâàíû âñåãî â 4% ñëó÷àåâ. B.J. Cole è A.A. Romeo [39] â òå÷åíèå 2 ëåò íàáëþäàëè 45 ïàöèåíòîâ-ñïîðòñìåíîâ, îïåðèðîâàííûõ òàêaeå ñ ïîìîùüþ ÿêîðíûõ ôèêñàòîðîâ. Èìè áûëî ïîëó÷åíî 96% õîðîøèõ è îòëè÷íûõ ðåçóëüòàòîâ. ...
... Ó ýòîé ãðóïïû ïàöèåíòîâ ìû èçó÷àëè ñâîéñòâà ãëåíîèäà ëîïàòêè, èçìåíåíèå êîòîðûõ ñïîñîáíî ïîâëèÿòü íà ñòàáèëüíîñòü ïëå÷åâîãî ñóñòàâà, à èìåííî ðàçìåðû ãëåíîèäà (âûñîòà, øèðèíà, ïëîùàäü), ïîâîðîò (àíòåâåðñèÿ, ðåòðîâåðñèÿ) è óãîë íàêëîíà [60]. Çà îñíîâó èçó÷åíèÿ âûøåóêàçàííûõ ïðèçíàêîâ áûëè âçÿòû ñòàòèñòè÷åñêèå äàííûå ïàðàìåòðîâ ãëåíîèäà ëîïàòêè ÷åëîâåêà, ãäå ñðåäíÿÿ âûñîòà ãëåíîèäà (glenoid height) íà îñíîâàíèè ðàçëè÷íûõ èññëåäîâàíèé [61] áûëà îïðåäåëåíà êàê 38 (33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45) ìì äëÿ ìóae÷èí è 36,2 (32,0-43,0) ìì -äëÿ aeåíùèí. Øèðèíà ãëåíîèäà (glenoid width) ðàâíÿëàñü 28,3 (24,0-32,0) ìì äëÿ ìóae÷èí è 23,6 (17,0-27,0) ììäëÿ aeåíùèí ñîîòâåòñòâåííî. ...
... 3 Contemporary arthroscopic techniques use suture anchors to secure the damaged capsulolabral complex to the glenoid and to tension the attenuated inferior glenohumeral ligament complex. 3,4 Knotless suture anchor techniques have been developed to maintain secure fixation of the labrum to the glenoid while avoiding potential irritation of the articular cartilage with suture knots. 5,6 Nevertheless, suture anchorsdwith or without knotsdleave intervening labral tissues without firm attachment to the glenoid rim. ...
... Two critical factors for a positive outcome of arthroscopic shoulder stabilization are re-tensioning of the inferior glenohumeral ligament and secure fixation of the labrum and capsule to the glenoid. 4 This article presents a novel arthroscopic technique designed to optimize secure fixation across the entire length of the capsulolabral complex. The main potential advantage of this technique is that the LabralTape provides secure fixation of the labral tissue between each suture anchor, creating some kind of seal; this provides a more uniform pressure distribution of the entire labrum when compared with traditional techniques, in which the labrum is secured only with "spot welds" at each anchor (Table 1). ...
Arthroscopic Bankart repair with suture anchors is widely considered a mainstay for surgical treatment of anterior shoulder instability after recurrent anterior shoulder dislocations. Traditionally, the displaced capsulolabral complex is restored and firmly attached to the glenoid by placing multiple suture anchors individually from a 5- to 3-o'clock position. A variety of different techniques using different anchor designs and materials have been described. Knotless anchors are widely used nowadays for shoulder instability repair, providing a fast and secure way of labral fixation with favorable long-term outcomes. However, these techniques result in a concentrated point load of the reduced labrum to the glenoid at each suture anchor. We describe a technique, developed by the first author, using a 1.5-mm LabralTape (Arthrex, Naples, FL) in combination with knotless suture anchors (3.5-mm PEEK [polyether ether ketone] PushLock anchors; Arthrex), for hybrid fixation of the labrum. The LabralTape is used to secure the torn labrum to the glenoid between each suture anchor, thus potentially providing a more even pressure distribution.
... Labral repair and capsulolabral reconstruction can effectively be treated with suture anchors by both arthroscopic and open methods. [1][2][3] Suture anchors are low-profile fixation devices that can minimize articular surface compromise and afford an anatomic reconstruction of the labrum and glenohumeral ligament complex. Although the use of suture anchors has become increasingly common to obtain stable fixation and healing at the bone-tendon interface in rotator cuff repair, critical distinctions exist between this function and their implementation in labral repair and capsulolabral reconstruction. ...
... Bioabsorbable suture anchors have several properties that make them a potentially attractive alternative to their nonabsorbable equivalents. 1,2,18 These include greater ease of postoperative imaging without the artifact associated with metallic devices as well as the potential restoration of bone stock after resorption. The resorption of suture anchors is a critical benefit, although not free of potential complications, because it may ease revision surgery, which is not uncommon when treating complex capsulolabral pathology. ...
Treatment of glenohumeral instability and capsulolabral pathology continues to evolve as arthroscopic techniques improve. A growing body of biomechanical and clinical research provides an enhanced perspective on results obtained with both arthroscopic and open treatment of these conditions. Labral repair and capsulolabral reconstruction can effectively be treated with suture anchors by both arthroscopic and open methods. Suture anchors are low-profile fixation devices that can minimize articular surface compromise and afford an anatomic reconstruction of the labrum and glenohumeral ligament complex. Although the use of suture anchors has become increasingly common to obtain stable fixation and healing at the bone-tendon interface in rotator cuff repair, critical distinctions exist between this function and their implementation in labral repair and capsulolabral reconstruction. This article examines the technical aspects of labral repair and capsulolabral reconstruction with metallic and bioabsorbable suture anchors. The emphasis is on implant options, technical advantages, potential limitations, and relevant biomechanical considerations to better achieve an optimal outcome.
... In recent years, arthroscopic shoulder technology has developed rapidly, with the strengths of less trauma, quick recovery, and reducing the patient's fear of surgery (19) . Therefore, arthroscopic repair is widely used for treating large rotator cuff tear (20) . ...
... In instances where bone loss is not present, the capsulolabral soft tissue is repaired anatomically via open or arthroscopic means, referred to as a Bankart procedure. With increasing recognition of combined posterosuperior humeral head impaction, known as a Hill-Sachs lesion, this procedure has been increasingly coupled with tethering or tenodesis of the infraspinatus tendon into the Hill-Sachs lesion, known as a "remplissage" procedure [12][13][14]. Instances of significant bone loss (> 25%) are commonly treated with a non-anatomic reconstruction involving a bone transfer known as a "Latarjet" coracoid transfer procedure [15]. ...
... In instances where bone loss is not present, the capsulolabral soft tissue is repaired anatomically via open or arthroscopic means, referred to as a Bankart procedure. With increasing recognition of combined posterosuperior humeral head impaction, known as a Hill-Sachs lesion, this procedure has been increasingly coupled with tethering or tenodesis of the infraspinatus tendon into the Hill-Sachs lesion, known as a "remplissage" procedure [12][13][14]. Instances of significant bone loss (> 25%) are commonly treated with a non-anatomic reconstruction involving a bone transfer known as a "Latarjet" coracoid transfer procedure [15]. ...
Introduction
Anterior dislocations, the most common type of shoulder dislocation, are often complicated by subsequent instability. With recurrent dislocations there often is attrition of the labrum and progressive loss of the anterior bony contour of the glenoid. Treatment options for this pathology involve either soft tissue repair or bony augmentation procedure. The optimal management remains unknown and current clinical practice is highly varied.
Methods and analysis
The Shoulder instability Trial comparing Arthroscopic stabilization Benefits compared with Latarjet procedure Evaluation (STABLE) is an ongoing multi-centre, pilot randomized controlled trial of 82 patients who have been diagnosed with recurrent anterior shoulder instability and subcritical glenoid bone loss. Patients are randomized to either soft tissue repair (Bankart + Remplissage) or bony augmentation (Latarjet procedure). The primary outcome for this pilot is to assess trial feasibility and secondary outcomes include recurrent instability as well as functional outcomes up to two years post-operatively.
Conclusions
This trial will help to identify the optimal treatment for patients with recurrent shoulder instability with a focus on determining which treatment option results in reduced risk of recurrent dislocation and improved patient outcomes. Findings from this trial will guide clinical practice and improve care for patients with shoulder instability.
Trial registration
This study has been registered on http://www.ClinicalTrials.gov with the following identifier: ClinicalTrials.gov Identifier: NCT03585491, registered 13 July 2018, https://www.clinicaltrials.gov/ct2/show/NCT03585491?term=NCT03585491&draw=2&rank=1 .
Ethics and dissemination
This study has ethics approval from the McMaster University/Hamilton Health Sciences Research Ethics Board (REB) (approval #4942). Successful completion will significantly impact the global management of patients with recurrent instability. This trial will develop a network of collaboration for future high-quality trials in shoulder instability.
... After portal placement and diagnostic arthroscopy, the anteroinferior glenoid rim and labrum were debrided and rasped to achieve sufficient bony bleeding. 17 At least two to four suture anchors were placed on the cartilaginous margin of the glenoid rim at the 5:30-to 2-o'clock position. The glenoid labrum with the capsuloligamentous complex was then lifted up and tied with a sliding suture technique. ...
Objectives
The primary aim of this study was to compare the clinical outcomes of patients undergoing arthroscopic Bankart repair and the open Latarjet procedure for recurrent dislocation of the shoulder. The secondary aims were to assess and compare the surgical cost, patient satisfaction, and complications, including recurrence and infection.
Methods
We retrospectively compared the clinical outcomes of all consecutive patients undergoing either arthroscopic Bankart repair or the open Latarjet procedure from May 2015 to May 2018 with a minimum 2-year follow-up. Forty-one patients (32 men, 9 women) in the Bankart group and 40 patients (34 men, 6 women) in the Latarjet group were available for the final follow-up.
Results
There were no statistically significant differences in the demographic parameters or clinical outcomes between the two groups. Functional satisfaction was higher with the Latarjet procedure. Bankart repair had a significantly higher operating cost than the Latarjet procedure. Three patients in the Bankart group and no patients in the Latarjet group developed recurrence.
Conclusion
Both procedures provided satisfactory clinical outcomes. However, the Latarjet group had a higher rate of functional satisfaction and lower operating cost, and there was a trend toward higher recurrence in the arthroscopic Bankart group.
... Possible portal placements, including posterior portal (viewing portal) and anterosuperior and anteroinferior portals (working portals), were also drawn with a sterile marker. After the portal placement and diagnostic arthroscopy, anteroinferior glenoid rim and labrum were debrided and rasped to make su cient bony bleeding [23]. At least 2 to 4 suture anchors (LUPINE (DePuy-Synthes)) were placed on the cartilaginous margin of the glenoid rim at 5:30 to 2 o'clock position. ...
Background The primary aim of this study was to compare the clinical outcomes of patients undergoing arthroscopic Bankart repair and open Latarjet procedure for recurrent dislocation of the shoulder. Secondary aims were to assess and compare the cost-effectiveness, satisfaction and complications, including recurrence and infection.
Methods We retrospectively evaluated the patients who underwent either arthroscopic Bankart repair with or without Remplissage procedure or open Latarjet procedure between May 2015 and May 2018. The preoperative data were collected from the hospital records, and the postoperative data were collected during the follow-up visit. At the final follow-up, 41(male=32, female=9) patients in the Bankart group and 40(male=34 and female=6) patients in the Latarjet group were included in the study. Clinical outcomes were assessed using the ASES score, Rowe score, and Quick DASH score. A self-constructed scale that consisted of satisfied and dissatisfied was used to measure the level of satisfaction. Any complications were recorded in every follow-up visit. Collected data were analyzed using SPSS version 25.
Results There was no statistically significant difference regarding the age (p=0.401), gender (p=0.569), site of involvement (p=0.158), number of preoperative dislocations (p=0.085), follow-up (p=0.061), between the two groups. Similarly, no statistically significant difference existed regarding the ASES score (p=0.388), Rowe score (p=0.211), and Quick DASH score (p=0.713). The average external rotation was 83 degrees in the Bankart group and 85 degrees in the Latarjet group (p=0.140). Functional satisfaction was higher in the Laterjet group compared to the Bankart group (p=0.482). Hundred percent of the patients were cosmetically satisfied in the Bankart group, whereas only 32(80%) patients were cosmetically satisfied in the Latarjet group (p=0.002). There was a significantly higher operating cost for arthroscopic Bankart repair compared to open Latarjet procedure (p<0.001). Three patients had a recurrence in the Bankart group, whereas no recurrence occurred in the Latarjet group. And, 2 superficial infections occurred in the Latarjet group.
Conclusion These results provide the fact that arthroscopic Bankart repair might be a fancy and minimally invasive procedure, Latarjet procedure should still be a priority in a developing country like Nepal, where financial cost is a huge burden.
... 20 An arthroscopic Bankart procedure is the most common and widely used surgical intervention to treat this disorder. 4 In this operation, the torn labrum and inferior glenohumeral ligaments are anatomically reattached to the glenoid rim with suture anchors 5,24 to re-establish the anatomy and stability of the joint. ...
Background
An arthroscopic Bankart operation is the most common operative procedure to treat shoulder instability. In case of recurrence, both Bankart and Latarjet procedures are used as revision procedures. The purpose of this study was to compare the re-recurrence rate of instability and clinical results after arthroscopic revision Bankart and open revision Latarjet procedures following failed primary arthroscopic Bankart operations.
Methods
Consecutive patients operatively treated for shoulder instability at Turku University Hospital between 2002 and 2013 were analyzed. Patients who underwent a primary arthroscopic Bankart operation followed by a recurrence of instability and underwent a subsequent arthroscopic Bankart or open Latarjet revision operation with a minimum of 1 year of follow-up were called in for a follow-up evaluation. The re-recurrence of instability, Subjective Shoulder Value, and Western Ontario Shoulder Instability index were assessed.
Results
Of 69 patients, 48 (dropout rate, 30%) were available for follow-up. Recurrent instability symptoms occurred in 13 patients (43%) after the revision Bankart procedure and none after the revision Latarjet procedure. A statistically and clinically significant difference in the Western Ontario Shoulder Instability index was found between the patients after the revision Bankart and revision Latarjet operations (68% and 88%, respectively; P = .0166).
Conclusions
The redislocation rate after an arthroscopic revision Bankart operation is high. Furthermore, patient-reported outcomes remain poor after a revision Bankart procedure compared with a revision Latarjet operation. We propose that in cases of recurring instability after a failed primary Bankart operation, an open Latarjet revision should be considered.
... O en el caso de que presente el paciente clínica de lesión de la porción larga del bíceps y en la artroscopia se muestre una lesión que sea subsidiaria de tratamiento quirúrgico, añadir al Bankart la reparación del SLAP, siendo la lesión que más frecuentemente hemos encontrado que precisó cirugía la de tipo II. En el caso de presentar una lesión de Hill-Sachs de la cabeza humeral muy grande o enganchada se realizaría la técnica de remplissage (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16) . En 7 pacientes se encontraron lesiones del manguito rotador. ...
... 16 In general, length of stay and post-operation pain are lower in the arthroscopic method and better cosmetic results can be achieved. 17 On the other hand, in open procedures, motion limitation and decreased function are more common. The disadvantages of arthroscopic procedures consist of the length of the learning curve as well as more dislocation relapse compared to open procedures. ...
Rotator cuff tear stands as one of the major origins of shoulder discomfort and disability, especially in elderly patients over 60 years. Improvement of performance and reduction of pain hardly occur in patients with contracted rotator cuff tear. Despite therapeutic advances, yet there are many discussions over choosing the best type of treatment for major rotator cuff tear. Complete care of massive rotator cuff tear continues to be a challenge in shoulder surgery. Treatment options have changed in comparison with traditional treatment methods in open or arthroscopic debridement surgery with or without decompression. Recently, many treatments have been introduced, including a range of non-surgical treatments, acromioplasty by debridement, minor repair biceps tenotomy, tuberoplasty by biceps tenotomy, minor repair, mini-open rotator cuff repair, arthroscopic rotator cuff, muscle movement, reverse shoulder arthroscopy, soft tissue reinforcement and hemiarthroplasty. Non-surgical massive rotator cuff control is typically assigned for patients with insignificant pain. This therapy functions by changing activities, proper use of steroid injections and physical therapy with an emphasis on the anterior deltoid exercises. But the main problem is the selection of the best treatment and making the final decision. In general, in the arthroscopic, morbidity, postoperative pain along with hospital stay are less and the operation has better cosmetic results. So this information and our results have prompted us to study a variety of rotator cuff treatment methods with a focus on the arthroscopic treatment.
... 32 , 33 Arthroscopic placement of suture anchors was first described by Wolf in 1993, 34 and was shown separately by Kim et al and by Cole and Romeo to have very low rates of recurrence (0-4%) and excellent rates of return of function. 35 , 36 In a patient with a clear history, examination and plain radiograph consistent with an uncomplicated first-time shoulder dislocation without bone pathologies, first line surgical management is usually a labral repair. In a patient with features suggestive of further pathology, CT arthrogram is most accurate to detect bone loss, but MR arthrogram is often sufficient and is better for detection of soft tissue pathology. ...
Glenohumeral dislocation is a common emergency department presentation. It is most often a traumatic anterior dislocation and occurs most frequently in young, active male patients. Shoulder instability and further dislocations may occur following primary dislocation, and these are associated with shoulder joint pathology and loss of function. Younger patients are more likely to experience further instability events, while shoulder dislocation is more often a singular event in older patients. There is debate regarding whether first time dislocators should be managed surgically or conservatively. This article discusses the evidence in the literature and current guidelines for the management of first time shoulder dislocation, proposing surgical management for young active patients following a first-time dislocation, most often an arthroscopic labral repair.
... Die Refixation des kaspulolabralen Gewebes an den vorderen unteren Pfannenrand erfolgt bei einer arthroskopischen Labrumrekonstruktion meist mittels einfacher horizontaler Nähte und einer unterschiedlichen Anzahl von Fadenankern [1]. ...
... Traditionally arthroscopic repair is performed using multiple suture anchors and a minimum of 3 anchors is perceived to be necessary to achieve optimum results restoring the labral "bumper". [5,6] The idea of using a single anchor and adapt the open vertical apical suture technique described by S. Copeland [7] in the form of "purse-string" technique was first described in 2006 by O. Levy [8] and was found to be at least as successful as multiple anchor techniques [9]. Since then one more centre has published results using the "purse-string" technique to achieve successful arthroscopic shoulder stabilization [10]. ...
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.
... R ecurrent anterior shoulder instability is a disabling condition that is commonly treated with either an arthroscopic Bankart repair 1,2 or an open Latarjet 3 procedure. After arthroscopic Bankart repairs, instability recurrence rates have been reported to range from 0% to 37.5% 4,5 , while recurrence rates after the open Latarjet procedure have been reported to range from 1.7% to 14.2% [6][7][8][9][10][11] , such that the latter is considered to restore stability better than the arthroscopic Bankart repair 12 . ...
Background:
Various operative techniques are used for treating recurrent anterior shoulder instability, and good mid-term results have been reported. The purpose of this study was to compare shoulder stability after treatment with the 2 commonly performed procedures, the arthroscopic Bankart soft-tissue repair and the open coracoid transfer according to Latarjet.
Methods:
A comparative, retrospective case-cohort analysis of 360 patients (364 shoulders) who had primary repair for recurrent anterior shoulder instability between 1998 and 2007 was performed. The minimum duration of follow-up was 6 years. Reoperations, overt recurrent instability (defined as recurrent dislocation or subluxation), apprehension, the subjective shoulder value (SSV), sports participation, and overall satisfaction were recorded.
Results:
An open Latarjet procedure was performed in 93 shoulders, and an arthroscopic Bankart repair was done in 271 shoulders. Instability or apprehension persisted or recurred after 11% (10) of the 93 Latarjet procedures and after 41.7% (113) of the 271 arthroscopic Bankart procedures. Overt instability recurred after 3% of the Latarjet procedures and after 28.4% (77) of the Bankart procedures. In the Latarjet group, 3.2% of the patients were not satisfied with their result compared with 13.2% in the Bankart group (p = 0.007). Kaplan-Meier analysis of survivorship, with apprehension (p < 0.001), redislocation (p = 0.01), and operative revision (p < 0.001) as the end points, documented the substantial superiority of the Latarjet procedure and the decreasing effectiveness of the arthroscopic Bankart repair over time. Twenty percent of the first recurrences after arthroscopic Bankart occurred no earlier than 91 months postoperatively, as opposed to the rare recurrences after osseous reconstruction, which occurred in the early postoperative period, with only rare late failures.
Conclusions:
In this retrospective cohort study, the arthroscopic Bankart procedure was inferior to the open Latarjet procedure for repair of recurrent anterior shoulder dislocation. The difference between the 2 procedures with respect to the quality of outcomes significantly increased with follow-up time.
Level of evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
... Among the available techniques, the 2 most commonly used are the transposition of the coracoid (open Bristow-Latarjet technique) 15,21,29 and the arthroscopic stabilization by tensioning of the capsule and repair of the labral lesion (arthroscopic Bankart procedure). 2,12,16,20 Evidence-based data exist supporting the efficacy of both procedures, § and the surgeon's personal preference plays a significant role in the choice of one of these techniques over the other. 36 Supporters of the transposition of the coracoid justify their choice based mainly on a lower recurrence rate and a better return to the patients' preinjury sport activity levels, especially if the patients participate in collision sports. ...
Background:
The arthroscopic Bankart repair and open Bristow-Latarjet procedure are the 2 most commonly used techniques to treat recurrent shoulder instability.
Purpose:
To compare in a case control-matched manner the 2 techniques, with particular emphasis on return to sport after surgery.
Study design:
Cohort study; Level of evidence, 3.
Methods:
A study was conducted in 2 hospitals matching 60 patients with posttraumatic recurrent anterior shoulder instability with a minimum follow-up of 2 years (30 patients treated with arthroscopic Bankart procedure and 30 treated with open Bristow-Latarjet procedure). Patients with severe glenoid bone loss and revision surgeries were excluded. In one hospital, patients were treated with arthroscopic Bankart repair using anchors; in the other, patients underwent the Bristow-Latarjet procedure. Patients were matched according to age at surgery, type and level of sport practiced before shoulder instability (Degree of Shoulder Involvement in Sports [DOSIS] scale), and number of dislocations. The primary outcomes were return to sport (Subjective Patient Outcome for Return to Sports [SPORTS] score), rate of recurrent instability, Oxford Shoulder Instability Score (OSIS), Subjective Shoulder Value (SSV), Western Ontario Shoulder Instability Index (WOSI), and range of motion (ROM).
Results:
After a mean follow-up of 5.3 years (range, 2-9 years), patients who underwent arthroscopic Bankart repair obtained better results in terms of return to sport (SPORTS score: 8 vs 6; P = .02) and ROM in the throwing position (86° vs 79°; P = .01), and they reported better subjective perception of the shoulder (SSV: 86% vs 75%; P = .02). No differences were detectable using the OSIS or WOSI. The rate of recurrent instability was not statistically different between the 2 groups (Bankart repair 10% vs Bristow-Latarjet 0%; P = .25), although the study may have been underpowered to detect a clinically important difference in this parameter. The multiple regression analysis showed that the independent variables associated with return to sport were preoperative DOSIS scale, type of surgery, and recurrent dislocations after surgery. Patients who played sports with high upper extremity involvement (eg, swimming, rugby, martial arts) at a competitive level (DOSIS scale 9 or 10) had a lower level of return to sport with both repair techniques.
Conclusion:
Arthroscopic stabilization using anchors provided better return to sport and subjective perception of the shoulder compared with the open Bristow-Latarjet procedure in the population studied. Recurrence may be higher in the arthroscopic Bankart group; further study is needed on this point.
... Moreover, it is often impossible to place anchors close enough around the 6-o'clock position as recommended in traditional labral repairs of other areas. 11 This creates a larger-than-desired gap between the points of fixation at the inferior labral repair. Other technical challenges are the tight working space of the inferior glenohumeral joint and the angle of knot tying, which many times results in a knot placed at the articular side of the labrum and interposed between the humeral head and the glenoid, which can cause articular cartilage damage and knot loosening. ...
Inferior labrum anterior to posterior lesions as an isolated injury or as part of an extensive traumatic labral tear are uncommon and may present as multidirectional instability of the shoulder. These lesions are hard to visualize radiographically and many times are diagnosed only during surgery. Arthroscopic repair of these lesions requires advanced arthroscopic skills and is required for restoration of glenohumeral stability. We report a combined double-pulley simple knot technique that anatomically reconstructs the inferior labrum while overcoming the typical technical challenges, providing a large footprint for healing along the inferior glenoid rim and minimizing the amount of suture material in direct contact with the articular cartilage and the risk of knot migration.
... 111 Anchors also facilitated fixation along the glenoid articular edge, as opposed to the medial neck, which had previously re-created anterior labral periosteal sleeve avulsion (ALPSA) lesions. 1 In 2002 Abrams et al 1 reported just a 5% recurrence rate in 662 patients after 2 years, and additional literature has continued to show recurrence rates below 10% for classic Bankart lesions. 24,74,118 For this reason, suture anchors are still the most popular mode of arthroscopic repair today. In 2001 Thal 144 introduced the knotless suture anchor wherein suture is passed through avulsed capsulolabral tissue and then passed without tying through an anchor that is impacted into the glenoid surface. ...
Background:
Anterior glenohumeral instability most commonly affects younger patients and has shown high recurrence rates with nonoperative management. The treatment of anterior glenohumeral instability has undergone significant evolution over the 20th and 21 centuries.
Methods:
This article presents a retrospective comprehensive review of the history of different operative techniques for shoulder stabilization.
Results:
Bankart first described an anatomic suture repair of the inferior glenohumeral ligament and anteroinferior labrum in 1923. Multiple surgeons have since described anatomic and nonanatomic repairs, and many of the early principles of shoulder stabilization have remained even as the techniques have changed. Some methods, such as the Magnusson-Stack procedure, Putti-Platt procedure, arthroscopic stapling, and transosseous suture fixation, have been almost completely abandoned. Other strategies, such as the Bankart repair, capsular shift, and remplissage, have persisted for decades and have been adapted for arthroscopic use.
Discussion:
The future of anterior shoulder stabilization will continue to evolve with even newer practices, such as the arthroscopic Latarjet transfer. Further research and clinical experience will dictate which future innovations are ultimately embraced.
... † However, recent advances in arthroscopic techniques and reports in the literature of their use have suggested that arthroscopic repair using suture anchors augmented with capsular plication may be a viable alternative that more closely parallels the open repair technique. 1,7,11,15,36,37 There are advantages to arthroscopic repairs. Green and Christensen 18 reported that arthroscopic shoulder surgery resulted in decreased blood loss, narcotic use, hospital stay, time lost from work, and complications when compared with open surgery. ...
... Arthroscopic anchors are widely used in the treatment of superior glenoid labral pathology. 1,2 The relatively narrow shape of the glenoid in cross section indicates that optimum performance of such anchors relies on accurate insertion. At the inferior glenoid, a deviation in insertion angle by as little as 20º can significantly decrease fixation strength. ...
Purpose:
To measure the angular relationship between the Neviaser portal and the superior glenoid labrum in 60 cadaveric specimens to determine whether this portal can be used for reliable anchor placement.
Methods:
The Neviaser portal of 30 left and 30 right unpaired dry cadaveric scapulae with clavicles were measured by a single observer using an analogue vernier caliper. The angular relationship between the Neviaser portal and the 12 o'clock position of the glenoid labrum was calculated.
Results:
13 of the 60 scapulae were excluded from analysis, because the Neviaser portal was medial to the glenoid rim making safe anchor insertion unfeasible. For the remaining 47 scapulae, the mean angles α and β were 58.2º and 57.9º, respectively. Compared with the ideal angles α and β of 30º and 0º, respectively, all the 47 Neviaser portals were more posterior (relative to the 12 o'clock position) and closer to the transverse plane, making insertion of suture anchors in the optimum position unfeasible, except for one that was within 10º of the ideal angles in both planes.
Conclusion:
Reliable insertion of suture anchors at the 12 o'clock position of the glenoid labrum through the Neviaser portal is unfeasible in most patients.
... With the inability to place direct inferior anchors, it is often impossible to place anchors close enough together at each "mark on the clock face" as recommended in traditional labral repairs. [31,32] To address this difficulty, we have utilized the technique of placing anchors at the 6:30 and 5 o'clock positions anteriorly and posteriorly, respectively, for the left shoulder. This would then essentially tether the labrum on both sides, preventing any motion of the labrum so that it could heal to the wellprepared bone bed despite not having a 6 o'clock anchor. ...
We describe the presentation, exam findings, surgical repair techniques, and short-term outcomes in a series of patients with isolated inferior labral tears.
A retrospective chart review was performed at a large academic medical center. Isolated inferior labral tears were defined as between the 4 o'clock and 8 o'clock position of the glenoid as determined by direct arthroscopic visualization. Tears that were smaller were also included but were required to cross the 6 o'clock point, having anterior and posterior components. Patients were excluded if they had any other pathology or treatment of the shoulder. 1-year follow-up was required.
Of the 17 patients who met inclusion criteria for review, 12 were available for a minimum 1-year follow-up. Average total follow-up for patients to complete the phone interview/Oxford Shoulder Instability Score (OSIS) was an average of 37.7 months (range: 16-79 months). Postoperatively, all reported symptom improvement or resolution since surgery. The mean preoperative pain on a scale of 0-10 was 6.3 (range: 0-10). Mean postoperative pain on a scale of 0-10 was 2.25 (range: 0-5). Eleven of 12 patients (91.7%) had returned to the level of activity desired. The mean OSIS was 41.4 (median: 43; range: 27-47). Eleven of 12 patients (91.7%) had good or excellent scores. Ten of 12 patients (83.3%) had a feeling of stability in the shoulder. All 12 patients reached were satisfied with the procedure and would undergo surgery again in a similar situation.
We have presented our series of patients with isolated inferior labral injury, and have shown that when surgically treated, outcomes of this uncommon injury are good to excellent and a full return to sports can be expected.
... The advent of suture anchors has allowed for the replacement of transosseous tunnels, especially in cases of glenohumeral instability. Using suture anchors on the glenoid rim or in the humerus eases and diminishes the time required for surgical repair of the capsule ligament, regardless of whether these are treated through open or arthroscopic routes [1][2][3][4][5][6][7][8]. However, despite the advantages provided by suture anchors, complications can still develop. ...
... . 현재 사용되고 있는 봉합나사못들은 고정 실패, 해 리, 돌출 등의 문제점들이 발생할 수가 있으며 봉합나 사못의 관절내 문제 발생으로 인한 봉합나사못 관절증 (suture anchor arthropathy)이라는 새로운 병명이 생기기까지 하였다 3,4,[7][8][9]12,15,17,18,[21][22][23][24][25]27) . 초기 금속재질 봉 합나사못의 문제점들을 해결하고 자 현재는 생 흡수성 봉합나사못이 주로 사용되고 있는데 이 역시 견갑와의 골 용해 및 이로 인한 관절증 4,16,24) , 나사못의 분절 및 위치이탈 3,15,23,27) , 활액막염 7) 등의 문제들이 보고되고 있 으며 또한 나사못 삽입중 쉽게 부러지기도 하여 고정 실패의 문제들이 발생하기도 하며 장기적으로는 흡수성 나사못이 관절내에서 일으킬 수 있는 염증 반응에 대한 연구가 아직 되어있지 않아 안정성이 확립되어 있지 않 은 상태이다 3,5,11,24,18,26,27) The guide pipe component. ...
Purpose: Too develop a flexible drill device that can be inserted into the shoulder joint so that arthroscopic transosseous suture repair for Bankart lesion is possible. Materials and Methods: We created a device composed of a flexible drill unit and a guide pipe unit. The flexible drill unit was made of flexible multifilament wires (1.2 mm in diameter) that was twisted into one cord so that it can flex in any direction and a drill bit (1.2 mm in diameter) that is attached onto one end of the flexible wire. The guide pipe unit was a 150 mm long metal pipe (2.0 mm in inner diameter and 3.0 mm in outer diameter), with one end bent to 30 degrees. The flexible drill set was inserted into the shoulder joint through the posterior portal of the joint. The guide pipe component was placed onto the medial wall of the glenoid so that the pipe was placed 5 mm posterior to the margin of the anterior glenoid rim. The flexible drill was driven through the glenoid by the power drill so that holes were made in the glenoid. A non- absorbable suture was passed through the hole. Tying of a sliding knot tying was accomplished over the capsule and labrum after making a stitch through the capsule and labrum with a suture hook loaded with suture passer. The same procedures were done at the 2 and 4 O'Clock positions of the glenoid. Results: Five cases with Bankart lesion received arthroscopic transosseous repair with our flexible drill device. There were no intraoperative problems. Neither redislocation nor subluxation was reported at final follow-up. Conclusion: Arthroscopic transosseous suture repair without suture anchors and easy tying of a sliding knot are possible with a flexible drill set.
... Traumatic anterior glenohumeral instability has been well characterized in the literature [3,4,6,12,24,33]; however, isolated anterior glenohumeral instability is also known to occur in the absence of a gross lesion to the labral soft tissue or bony glenoid rim. This has been discussed in the context of athletes dependent on overhead motion of the upper extremity for competition, such as baseball pitchers and swimmers [2,13,16,17]. ...
The purpose of this study was to determine the effect of a stepwise arthroscopic anterior plication and arthroscopic-equivalent rotator interval (RI) closure on glenohumeral range of motion, kinematics, and translation in the setting of anterior instability.
Six cadaveric shoulders were stretched to 10 % beyond maximum external rotation (ER) to create an anterior shoulder instability model. Range of motion, kinematics, and glenohumeral translations were recorded for the following conditions: (1) intact, (2) stretched, (3) after anterior capsular plication, and (4) after RI closure.
The total range of motion after capsular stretching increased significantly in the 60° abduction position (p = 0.037). Average ER and total rotation were significantly decreased from the intact and stretched conditions by both repair conditions at 60° and 0° of glenohumeral abduction (p < 0.05), with no significant difference between plication and additional RI closure. At 0° abduction and 0° ER, glenohumeral translation decreased significantly from the stretched condition after RI closure with 10 and 15 N anterior and 10 N posterior loads (p < 0.05). At 30° ER, translation after RI closure was significantly less than both the intact and stretched conditions with 10 N anterior loads (p = 0.009; p = 0.004). These changes in translational stability were not seen with plication alone.
Anterior capsular plication reduced glenohumeral range of motion back to the intact state, and often tighter. RI closure did not contribute significantly to the reduction in the range of motion, but had implications regarding glenohumeral translation. Caution should be taken when performing anterior plication and combined repairs to avoid overtightening. Intraoperative translations could be useful when debating RI closure in patients with unidirectional anterior glenohumeral instability.
... Multiple studies have documented improved shoulder function and decreased recurrent dislocation rates with this technique. 8,9 Several recent studies have noted that recurrent instability is directly related to the amount of anterior bone loss, and preserving bone is imperative to repair techniques. 10,11 The most essential part of surgical repair involves stable fixation of the bony Bankart lesion in an effort to achieve osseous union and prevent recurrent instability. ...
The arthroscopic treatment of the "bony Bankart lesion" continues to evolve. We present a novel technique that we developed at Orthopaedic Research of Virginia, the "transosseous bony Bankart repair," which incorporates several essential concepts to provide for optimal healing and rehabilitation. We promote arthroscopic repair emphasizing bone preservation, a fracture interface without interposing sutures, the ability to reduce capsular volume, and multiple points of stable glenolabral fixation. Our technique positions suture anchors within the subchondral bone of the intact glenoid to allow for an anatomic reduction of the bony fragment. By use of an arthroscopic drill, spinal needle, and nitinol suture passing wire, the sutures are passed in a retrograde fashion through the bony Bankart fragment and anterior capsule in a mattress configuration. Additional inferior and superior anchors are placed to further provide stability and reduce capsular volume. While maximizing fracture surface area and optimizing bony healing, the end result is an anatomic reduction of the bony fragment and the glenoid articular surface.
... 5 These more anatomic repair types have been highly successful in the treatment of anterior instability in the setting of a traumatic Bankart lesions. 6,7 Unfortunately, despite improved clinical results, these procedures are not completely protective of the development of arthritis. In 1 study at 10-year follow-up, 39% of patients undergoing arthroscopic Bankart repair demonstrated evidence of radiographic arthritis. ...
Surgical treatment for traumatic shoulder instability has progressed in tandem with the evolution of the current understanding of the anatomy and biomechanics of the shoulder. Proponents of incorporating the middle glenohumeral ligament (MGHL) in Bankart repair believe this technique could increase repair strength. The purpose of this biomechanical study was to compare the range of motion and humeral head kinematic changes that result from including the MGHL in a Bankart repair in an effort to identify possible changes in shoulder biomechanics as a result of this addition in surgical repair.
Six cadaveric shoulders were tested in 4 conditions: intact, Bankart lesion, repair excluding the MGHL, and repair including the MGHL. Each condition was tested for range of motion, glenohumeral translation, and humeral head apex position. Standard Bankart repair and repair with MGHL inclusion resulted in decreased range of motion, but no statistically significant difference was found between the 2 repair types ( P =.846). Anterior translation was significantly reduced with both the Bankart repair (4.8±.9; P =.049) and included MGHL repair (4.6±0.9; P =.029). No statistically significant difference was found between both repairs ( P =.993). Although both repairs showed posterior displacement of the humeral head apex when in external rotation, this trend only reached statistical significance when compared with the Bankart lesion in 90° of external rotation ( P =.0456); however, no significant difference was found between the 2 repairs ( P =.999).
Inclusion or exclusion of the MGHL in a Bankart repair does not significantly affect the range of motion, translation, or kinematics of the glenohumeral joint.
... Anterior instability of the shoulder is treated surgically by open [1,2] or arthroscopic [3,4] Bankart repair [5], or by coracoid bone block (Latarjet procedure) [6,7]. Arthroscopic Bankart repair results in reinsertion of the labrum and tightening of the inferior glenohumeral ligament [8,9]. ...
Introduction and hypothesis:
The hypothesis of this study was that the rate of recurrence of anterior instability of the shoulder after arthroscopic Bankart repair with suture anchors is higher than after coracoid bone block (Latarjet procedure).
Materials and methods:
This continuous retrospective monocentric study included a cohort of patients who underwent surgery for post-traumatic recurrent antero-inferior instability (2004-2005): 51 patients who underwent an open Latarjet procedure were paired for age at surgery to 51 patients who underwent an arthroscopic Bankart repair. All patients were evaluated with a questionnaire and 50% were evaluated in a follow-up consultation with X-rays. Recurrent instability was defined by at least one episode of anterior dislocation or subluxation.
Results:
Demographic data, soft tissue and bone lesions were statistically similar between the groups. At 5 years follow-up, the recurrence rate was 24% in the Bankart group and 12% in the Latarjet group (P=012). In the Bankart group, age under 25 years old (P=0.01), competitive sports after surgery (P=0.01), and glenoid erosion (P=0.02) were independent risk factors of recurrence. In the Latarjet group, five technical errors were identified out of six cases of recurrence. Fifteen of the 18 cases of recurrence did not undergo revision surgery because patients remained satisfied with their results.
Discussion and conclusions:
At 5 years of follow-up, the rate of recurrent instability following arthroscopic Bankart repair was two times higher than that following the coracoid bone block procedure. Young patients who wish to practice a competitive sport or present with glenoid erosion are poor candidates for arthroscopic Bankart repair. The rate of recurrence is extremely high in unselected patients. The open Latarjet procedure results in a fairly high rate of recurrence due to technical errors.
Level of evidence:
Level IV (retrospective study).
... Bankartlesion) is one established cause for glenohumeral instability and a common injury in the young and active population. Arthroscopic restoration of the detached labrum contributes in means of maintaining stability as well as range of motion [5,7,13]. Although repair procedures are highly successful, failure still occurs [4,[11][12][13][14]22]. ...
The nature and the distribution of fibrocartilage at the human glenoid labrum are unclear, and a better understanding may help to restore its function in open and arthroscopic Bankart repair. Aim of this study was to describe the fibrocartilage extent within the labrum at clinically relevant sites of the glenoid in order to relate the molecular composition of the labrum to its mechanical environment.
Twelve fresh frozen human cadaveric shoulders (mean age 38 years) were obtained, and sections perpendicular to the glenoid rim at the 12, 2, 3, 4, 6 and 9 o' clock position were labelled with antibodies against collagen I and II, aggrecan and link protein.
A fibrocartilaginous transition zone with a characteristic collagen fibre orientation was found in 81% of cases, evenly distributed (83-92%) around the glenoid rim. The percentage of labrum cross-sectional area comprised of fibrocartilage averaged 28% and ranged from 26% at 12 o'clock on the glenoid clock face to 30% at 3 o'clock. The highest amount of fibrocartilage (82%) was found in the region neighbouring the hyaline articular cartilage. In the region beyond the bony edge of the glenoid, fibrocartilage cross-sectional area did not exceed 12-17%.
Fibrocartilage is present at all examined positions around the glenoid rim and constitutes up to 1/3 of the cross-sectional area of the labrum. In turn, the percentage of fibrocartilage in different regions of its cross-section varies considerably. The findings suggest that the penetration of fibrocartilaginous tissue may be reduced by avoiding the highly fibrocartilage transition zone during restoration of labral detachment.
Background: Anterior shoulder instability predominantly affects collegiate athletes, with a notable incidence of 0.12 per 1000 athletic exposures. Acute dislocations pose an orthopedic emergency requiring immediate repositioning to prevent complications such as brachial plexus or artery compression, avascular necrosis of the humeral head, and chronic disability. Conservative therapy often precedes surgical intervention due to concerns over recovery time, discomfort, decreased range of motion, and high recurrence rates. Objective: This study aims to compare the efficacy of Arthroscopic Bankart Repair and open Bristow-Latarjet Procedure in terms of pain reduction, return to normal activities, and improvement in Western Ontario Shoulder Instability (WOSI) score among patients with anterior shoulder joint instability. Methods: A 12-month comparative study was conducted at Lahore General Hospital from April 2022 to April 2023, following ethical review board approval. Thirty-two patients aged 18–32, with severe unidirectional dislocation, consented and participated. They were divided into two groups: Group A underwent Arthroscopic Bankart Repair, and Group B underwent the open Bristow-Latarjet Procedure. Results: The average age was 23 in Group B and 25 in Group A. Males comprised 80% of Group A and 68% of Group B. WOSI scores averaged 72 for Bankart and 76 for Latarjet. Rowe scores were 75 (Bankart) and 69 (Latarjet), with Quick DASH scores of 11 (Bankart) and 15 (Latarjet). External rotation was 77 degrees in Bankart and 73 degrees in Latarjet. Functional satisfaction was reported by 84.0% of Bankart and 11.7% of Latarjet patients. The cost of Latarjet was significantly lower than that of Bankart. Conclusion: The open Latarjet procedure demonstrated higher functional satisfaction and lower operational costs compared to Arthroscopic Bankart Repair, which exhibited a higher recurrence rate. Given the economic constraints in a developing country like Pakistan, Latarjet may be a more viable option despite the non-invasive appeal of Bankart Repair.
Purpose To evaluate the relationship between kinesiophobia and patient's return to sport after shoulder stabilization surgery. The hypothesis was that kinesiophobia represents an independent factor correlated to the difference between preinjury and postoperative level of sport.
Methods This study retrospectively evaluated 66 patients (mean age: 35.5, standard deviation [SD] = 9.9 years) and at a mean follow-up of 61.1 (SD = 37.5) months after arthroscopic Bankart's repair or open Bristow–Latarjet procedure. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK); return to the preinjury sport was assessed by the difference between baseline and postoperative degree of shoulder involvement in sport (D-DOSIS) scale. The Western Ontario Shoulder Instability index (WOSI) was used to evaluate participants' perceptions of shoulder function.
Results TSK showed correlation with D-DOSIS (ρ = 0.505, p < 0.001) and the WOSI score (ρ = 0.589, p < 0.001). There was significant difference in TSK and WOSI scores between participants who had and had not returned to their previous level of sport participation (p = 0.006, and 0.0001, respectively).
Conclusion This study demonstrated that kinesiophobia is correlated to the return to sport after shoulder stabilization surgery.
Level of Evidence Level IV, retrospective case series.
Anterior shoulder instability is the most common pattern of shoulder instability, with anterior dislocations accounting for over 90% of all dislocations. Open Bankart repair has been shown to have a low complication rate and remains an excellent surgical option for a select group of patients with risk factors for failure following arthroscopic stabilization which include: history of recurrent instability and/or ligamentous laxity, concomitant glenoid and humeral head osseous defects, male sex, young age, and contact athletes. This is particularly true for patients that are not candidates for bony glenoid augmentation procedures. Here we detail the patient indications, surgical technique, and patient outcomes following open Bankart repair.
The decision to manage first-time shoulder dislocations conservatively or operatively has become increasingly complex because of conflicting literature. Although shoulder dislocations have traditionally been managed with reduction and immobilization, recent evidence has suggested high rates of subsequent recurrence. Surgical intervention is thought to better restore stability and decrease recurrence rates; however, it also has the potential for additional morbidity and financial cost. As such, recent literature has sought to better define patient risk profiles to identify optimal candidates for both conservative and operative management. The purpose of the current review is to provide a comprehensive and evidence-based assessment of the most recent literature to better delineate an appropriate treatment algorithm for this challenging clinical scenario.
Ein 49-jähriger Patient stellt sich in einer Spezialklinik für arthroskopische Chirurgie und Sportmedizin mit Schulterschmerzen vor. Dort gibt er an, dass ihn die rechte Schulter seit den frühen 1980er-Jahren immer wieder schmerze. Da er nie körperlich gearbeitet habe und auch recht unsportlich sei, habe er sich mit der Situation lange Zeit arrangiert. Die Schulter fühle sich nun aber schon seit Jahren „instabil“ an. Er habe sie jedoch nie ausgekugelt, noch sei er je in einer ärztlichen Behandlung betreffend der Schulter gestanden. Da er seit einigen Monaten vermehrt eine schwere Aktentasche tragen müsse, störe ihn die Schulter nun aber im Alltag. Es stelle sich für ihn die Frage, ob dies nicht behandelt werden könne.
PurposeThe study aimed to compare modified arthroscopic subscapularis augmentation (MASA) with tenodesis of the upper third of the subscapularis tendon using a tendon combined with capsulolabral reconstruction (Group A) or Bankart repair (Group B) for recurrent anterior shoulder instability (RASI).MethodsA retrospective series of 49 patients underwent primary surgery for RASI with glenoid bone loss (GBL) < 25%. Outcomes included the Oxford Shoulder Instability Score (OSIS), Visual Analogue Scale (VAS) score, Rowe score, and American Shoulder and Elbow Surgeons (ASES) functional outcome scale score. Recurrent instability, sports activity level, and range of motion (ROM) were also analysed.ResultsNo significant differences were observed at baseline. Forty-six patients were available for more than 2 years of follow-up. At the last follow-up after surgery, the patients in both groups had experienced significant improvements in all outcome scores (P < 0.05 for all), and obvious decreases in forward flexion and external rotation were noted in both groups (P < 0.05 for all). Group A had superior ASES scores, VAS scores, and OSISs (P < 0.05) but did not experience significant differences in either the Rowe score or ROM compared to Group B. Group A had lower rates of recurrent instability and superior outcomes for the return to sports activities. One patient in Group A had subluxation, and 4 patients in Group B had dislocation or subluxation. No patients in either group experienced neurovascular injury, joint stiffness, or surgical wound infection.Conclusion
For RASI with GBL < 25%, MASA with tenodesis of the upper third of the subscapularis tendon using a tendon combined with capsulolabral reconstruction was a safe technique that produced better outcomes in terms of ASES scores, VAS scores, OSISs, the return to sports, and postoperative recurrent instability and did not decrease the ROM compared to that achieved by arthroscopic Bankart repair.Level of evidenceIII.
Background
The accuracy of surgeons in utilizing the clock face method for anchor placement has never been investigated. Our hypothesis was that shoulder arthroscopy surgeons would be able to place suture anchors at predetermined positions with accuracy and reliability.
Methods
Ten cadaveric shoulders were used. Five fellowship-trained shoulder arthroscopy surgeons were directed to place a suture anchor at 3:30, 4:30, and 5:30 clock in two shoulders each. The position of the anchors was determined with computed tomography. The accuracy of placement was calculated and data analyzed with one-way analysis of variance. The intraclass correlation coefficients were calculated.
Results
The overall accuracy was 57%. The accuracy of anchor placement at the 3:30 position was 40% (average position 2:24 o’clock), it was 50% at the 4:30 position (average position 3:42 o’clock) and 80% at the 5:30 position (average position 5:03 o’clock). No statistical difference in accuracy between the placement of the superior, middle, and inferior anchors (p = 0.145) was seen. The intraclass correlation coefficient for inter-surgeon reliability was 0.4 (fair) while the intraclass correlation coefficient for intra-surgeon reliability was 0.6 (moderate).
Discussion
The findings of this study suggest a moderate degree of accuracy and fair to moderate inter- and intra-surgeon reliability when using the clock face system to guide anchor placement.
Operative treatment of the unstable shoulder historically has a high success rate. However, the complication rate has risen. This article reviews the pearls and pitfalls to attempt to elucidate the etiology for these complications and failures. Preoperative assessment of the unstable shoulder ultimately is critical to avoid complications, including history, physical examination, and key radiographic features. Intraoperative techniques include appropriate soft tissue mobilization, multiple points of fixation, avoidance of hardware-related problems, and appropriate management of the capsule and bone defects. Finally, postoperative rehabilitation is equally important to regain physiologic range of motion in a safe, supervised fashion.
Glenohumeral stability is a result of a complex interplay between passive and active restraints that require intricate balance and synchronicity. The management of anterior shoulder instability is based on the natural history, associated injuries, and consideration of several characteristics such as age, gender, activity demands, and expectations. In the athletic population, the underlying pathoanatomy predisposing to further instability episodes and the individual needs of the athlete must be considered in determining the most appropriate treatment to prevent unnecessary absence from sport. With the advent of and rapid improvement in arthroscopic techniques, arthroscopic stabilization has become a frequently means of addressing anterior instability. However, the recurrence rate in athletes following an arthroscopic repair may be higher than desired due to a high prevalence of bony defects and high demand, particularly in contact athletes. Preoperative recognition and quantification of bony defects is therefore critical to success. This chapter explores the recent advances in epidemiology and classification of anterior shoulder instability in athletes, reviews the pathoanatomy and biomechanics clinical assessment of shoulder stability, and compares the relative merits and outcomes of the different forms of treatment.
Introduction et hypothèse
L’hypothèse de cette étude est que le taux de récidive d’instabilité antérieure de l’épaule du Bankart arthroscopique avec ancres est supérieur à celui de la butée coracoïdienne de Latarjet.
Patients et méthodes
Étude rétrospective monocentrique continue concernant une cohorte de patients tous opérés pour instabilité antéro-inférieure post-traumatique récidivante sur la même période (2004–2005) : 51 patients opérés par butée de Latarjet à ciel ouvert ont été appariés par l’âge au moment de la chirurgie à 51 patients opérés par Bankart arthroscopique. Tous les patients ont été évalués par un questionnaire et 50 % ont pu être revus en consultation avec des radiographies. Une récidive d’instabilité était définie par au moins un épisode de luxation ou de subluxation antérieure.
Résultats
Les deux groupes étaient statistiquement comparables pour les données démographiques et les lésions capsulo-ligamentaires et osseuses. Au recul moyen de cinq ans, le taux de récidive était de 24 % dans le groupe Bankart et de 12 % dans le groupe butée (p = 0,12). Dans le groupe Bankart, l’âge inférieur à 25 ans (p = 0,01), le sport de compétition après la chirurgie (p = 0,01) et un éculement glénoïdien (p = 0,02) constituaient des facteurs de risque indépendants de récidive. Dans le groupe butée, sur six récidives, cinq erreurs techniques ont été identifiées. Quinze des 18 récidives n’ont pas été réopérées car restaient satisfaits de l’opération.
Discussion et conclusions
À cinq ans de recul, le taux de récidive d’instabilité du Bankart arthroscopique est deux fois celui de la butée coracoïdienne. Les patients jeunes, souhaitant pratiquer un sport de compétition et présentant un éculement glénoïdien ne sont pas de bons candidats pour le Bankart arthroscopique. Celui-ci présente un taux de récidive rédhibitoire en l’absence de sélection des patients. La butée de Latarjet à ciel ouvert présente un taux de récidive non négligeable lié à des erreurs techniques.
Niveau de preuve
IV (étude rétrospective).
Athletes often expose their shoulders to significant forces and stresses and treatment of recurrent shoulder instability in this population is challenging. Recurrence after surgical shoulder stabilization in an athlete warrants a systematic approach to the diagnosis and treatment. The surgeon must develop a clear understanding of the etiology of the failure and take the necessary steps during the management algorithm to prevent a subsequent recurrence. When planning revision surgical stabilization, the surgeon must analyze and address risk factors for recurrence, which include younger age, contact/collision sports, higher level of competition, capsular laxity, glenoid bone loss, and engaging Hill-Sachs deformities. The surgeon must provide the athlete with the surgery that provides the best chance to return to sport and the lowest risk of recurrent instability. While revision arthroscopic Bankart repair may be appropriate in some cases in which there is minimal glenoid bone loss and robust labral and capsular tissue is available, an open procedure such as a Latarjet may be indicated for athletes at high risk for recurrence.
Mehr als 95 % der Schulterluxationen erfolgen nach ventral. Das Verletzungsmuster ist unterschiedlich, ein Labrumabriss zählt in mehr als 85 % dazu. Entscheidender sind die Prognose einer Rezidivluxation ist jedoch der zusätzliche Abriss des Lig. glenohumerale inferius und das Patientenalter. Ein Hill-Sachs-Defekt gewinnt erst ab einem Anteil von 30 % an der Humeruskopfzirkumferenz an Bedeutung. Die Indikation zur sofortigen Operation ist die verhakte, nicht geschlossen zu reponierende Verrenkung (zumeist nach dorsal). Frühzeitig sollten relevante Pfannenrandfrakturen sowie Labrum-Kapselabrisse bei jungen Patienten unter 26 Jahren und schulteraktiven Sportlern fixiert werden. Während noch vor wenigen Jahren diese vorderen Schulterluxationen geschlossen reponiert und unabhängig vom Alter sowie vom Leistungsprofil des Patienten früh-funktionell nachbehandelt wurden, setzt mit Entwicklung arthroskopischer minimal invasiver Techniken ein Umdenken zur Differenzierung ein. Vor einem allgemeinen Einsatz der Schulterarthroskopie nach vorderer Luxation sollte gewarnt werden, da es sich letztendlich um einen operativen Eingriff mit möglichen Nebenwirkungen handelt. Für den modernen Behandlungsalgorithmus ist zunächst eine strenge Trennung zwischen traumatischen und atraumatischen Erstluxationen anzustreben. Während die erste Gruppe nach dem TUBS-Schema (traumatisch-unilateral-Bankartläsion-surgery) von einer arthroskopischen Technik deutlich profitieren kann, gilt für die zweite Gruppe Zurückhaltung entsprechend dem sog. AMBRII-Schema (atraumatisch-multidirektional-bilateral-Rehabilitation vor inferiorem Kapselshift und Intervallverschluss). Anatomische artikularseitige Rekonstruktionen mit einer Refixation des Limbus-Kapselkomplexes nach Bankart werden heute als Standard bevorzugt, auch bei Rezidiven. Extraartikuläre Eingriffe sind individuellen Indikationen vorbehalten. Arthroskopische Verfahren erfordern ein aufwändiges und genau auf die Fixationstechnik abgestimmtes Equipment. Mit differenzierter Indikationsstellung, Patientenselektion und zunehmender Lernkurve gelingt es in aktuellen Studien die Erfolgsrate dem des offenen Bankartrepair anzunähern.
Background:
Rotator cuff repairs (RCRs) have become increasingly common. Several studies have shown variation in the indications for this procedure. We chose to track the incidence of RCRs in New York State (NYS) from 1995 to 2009. We hypothesized that after the introduction of the Current Procedural Terminology (CPT) code 29827 for arthroscopic RCR, there would be a significant increase in the rate of RCRs performed in NYS.
Materials and methods:
The NYS Department of Health's Statewide Planning and Research Cooperative System (SPARCS) database was queried for reported RCRs between the years 1995 and 2009. Using the International Classification of Diseases, Ninth Revision, Clinical Modification procedural code 83.63 and CPT codes 23410, 23412, 23420, and 29827, we collected and analyzed data on RCR procedures.
Results:
A total of 168,780 RCRs were performed in NYS from 1995 to 2009. In 1995, the population incidence of RCRs was 23.5 per 100,000. In comparison, in 2009, the population incidence was 83.1 per 100,000, an increase of 238% (P < .0001). The percentage of individuals aged between 45 and 65 years undergoing RCR increased from 53.0% to 64.2% during this same period.
Conclusions:
There has been a notable increase in the volume of RCRs performed in NYS. In addition, after the introduction of CPT code 29827 in 2003, the increase in the incidence of RCRs became significantly more pronounced.
Level of evidence:
Level III, cross-sectional design, epidemiology study.
The purpose of this study is to describe a new arthroscopic technique, the "Purse-String technique," which addresses the Bankart lesion and the capsule laxity, using a single suture anchor. The repair is 3-fold: firstly, a labral repair; secondly, the creation of an anterior bumper; and finally, a capsular shift. The technique has advantages in terms of technical simplicity, reduced operative time, and avoidance of multiple suture anchors. We describe the operative technique and clinical results.
An accessory trans-rotator cuff portal is commonly used in shoulder arthroscopy, primarily in the repair of SLAP (superior labrum anterior-posterior) lesions. Improper placement of the trans-rotator cuff portal can result in damage to the rotator cuff near its attachment site.
Six patients were studied, having been referred to our clinic after previous shoulder arthroscopy with SLAP repair. Review of operative notes showed that the rotator cuff had been described as normal in 5 patients and having a mild partial-thickness tear of the supraspinatus in 1 patient at the time of the first surgery. All patients underwent repeat shoulder arthroscopy within 10 to 22 months.
All 6 patients were found to have full-thickness rotator cuff tears at the time of the second surgery. The rotator cuff injuries appeared to be associated with portal placement from the previous SLAP repair. All patients underwent rotator cuff repair, and 3 had concomitant revision SLAP repair. All patients had clinical improvement, with a mean preoperative American Shoulder and Elbow Surgeons score of 45.3 and mean postoperative score of 90.5. Mean follow-up was 58.3 months.
Proper placement of a trans-rotator cuff portal should be performed cautiously, traversing the rotator cuff medial to the muscle-tendon junction. This report highlights the potential for injury to the rotator cuff tendons with improper placement of this portal. In patients with persistent pain after previous SLAP repair with a trans-rotator cuff portal technique, rotator cuff injury may be the source of symptoms. Revision surgery with rotator cuff repair can provide improvement.
The purpose of the study was to establish radiologic and clinical occurrence of glenohumeral arthrosis after arthroscopic Bankart repair.
Between January 1994 and December 1998, an arthroscopic Bankart repair was performed in 187 patients at our institution. We were able to assess clinical and radiologic glenohumeral arthrosis in 72 of the 101 patients who met the inclusion criteria (74 shoulders) (71%) after a 13-year follow-up. An additional 9 patients were interviewed by telephone. Radiologic arthrosis was evaluated with the Samilson-Prieto classification and clinical arthrosis with an arthrosis-specific quality-of-life questionnaire (Western Ontario Osteoarthritis of the Shoulder test). In addition, functional impairment was assessed with the Constant score and subjective satisfaction with a questionnaire.
Radiologic arthrosis was diagnosed in 50 of 74 shoulders (68%), with 40 (80%) of them classified as mild. The mean score on the Western Ontario Osteoarthritis of the Shoulder questionnaire was 280 points (85% of the best possible score), which is considered relatively good. The mean Constant score was 78 points, and 75% of the patients were extremely satisfied or satisfied with the final results of operative treatment.
The radiologic evaluation and self-assessment of the patients imply that the incidence of glenohumeral arthrosis after arthroscopic Bankart repair is quite common but the symptoms are generally mild and comparable to nonoperative treatment.
Arthrosis rarely causes more than minor subjective symptoms or a minor objectively perceived disadvantage during 13 years' follow-up.
This article reviews the natural history of the initial traumatic anterior shoulder dislocation. The literature is compared with the experience at the US Military Academy in a uniform group of young athletes. The concept and rationale for acute arthroscopic stabilization are introduced. Operative indications and the current arthroscopic technique are detailed.
Arthroscopic techniques have been successfully adapted and are a mainstay in many orthopedic practices. Thisprovides a large impetus for the continuing development of arthroscopic shoulder stabilization. The initial studies showed a much higher failure rate with these procedures as compared with traditional open procedures. However, for the last several years, there has been an increase in reliably positive reports. Several studies using suture anchors have had success rates approaching those of traditional open techniques. This summary will present a reproducible technique that, when performed in a well-chosen population, will result in a stable shoulder with the potential for preinjury activity levels.
The purpose of this study was to compare joint capsular healing after two delivery patterns of monopolar radiofrequency energy: 1) uniform treatment of the joint capsule (paintbrush pattern) and 2) multiple single linear passes (grid pattern). First, an in vitro study was performed to compare the percent shrinkage of these two treatment patterns using the femoropatellar joints (stifles) of six sheep. Monopolar radiofrequency energy (settings, 70°C/15W) was applied to the lateral joint capsule; the treated area was approximately 10 10 mm. There was no significant difference in shrinkage between the grid (27% 8.7%) and paintbrush (29% 7.9%) patterns. In the in vivo study, stifles of 24 sheep were randomly assigned to the paintbrush or the grid pattern groups and treatment was performed arthroscopically. Sheep were sacrificed immediately after surgery, or at 2, 6, or 12 weeks after surgery. At 6 weeks after surgery, confocal microscopy demonstrated that treated areas had almost completely repaired in the grid group; some nonviable areas were still present in the paintbrush group. Mechanical testing at 6 weeks indicated that joint capsule in the grid group had better mechanical properties than capsule in the paintbrush group. This study revealed that radiofrequency treatment of joint capsule in a grid pattern allowed faster healing than tissue treated in a paintbrush pattern.
Arthroscopic management of glenohumeral instability is increasingly recognized as an alternative to open reconstruction. Reports of recurrence rates continue to decrease because of improved techniques and a better understanding of the pathophysiology of shoulder instability. The indications and results may be improved on with the addition of thermal capsulorrhaphy using a radiofrequency probe to “shrink” the capsular regions contributing to residual laxity. We describe our surgical techniques and postoperative rehabilitation after thermal modification of the glenohumeral joint.
The inferior glenohumeral ligament (IGHL) is an important structure for maintaining shoulder stability. This study was aimed at determining the geometric and anatomic characteristics of the IGHL and its tensile properties at a higher strain rate than previously tested. Eight fresh-forzen human cadaver shoulders (average age 69 years, age range 62 to 73 years) from four female and four male cadavers were used to harvest bone-ligament-bone specimens from the three regions of the IGHL (superior band, anterior axillary pouch, and posterior axillary pouch). Uniaxial tensile tests were performed at the moderately high strain rate of approximately 10% per second with a servo-hydraulic testing machine. This represented a strain rate that was approximately 100 to 1000 times faster than that previously reported. During tensile testing, bone-ligament-bone strains were calculated from grip-to-grip motion on the testing machine, and mid-substance strains were determined by a video dimensional analyzer. Although all regions of the IGHL had similar lengths (averaging 43.4 mm), their thickness varied by region and by proximal-to-distal location. The superior band was the thickest (2.23±0.38 mm) of the three regions. Of the remaining two regions the anterior axillary pouch (1.94±0.38 mm) was thicker than the posterior axillary pouch (1.59±0.64 mm). By proximal-to-distal location the IGHL was thicker for all three regions near the glenoid (2.30±0.57 mm) than near the humerus (1.61±0.52 mm). The superior band had a greater stiffness (62.63±9.78 MPa) than either the anterior axillary pouch (47.75±17.89 MPa) or the posterior axillary pouch (39.97±13.29 MPa). Tensile stress at failure was greater in the superior band (8.4±2.2 MPa) and the anterior axillary pouch (7.8±3.1 MPa) than the posterior axillary pouch (5.9±1.7 MPa). The anterior axillary pouch demonstrated greater bone-to-bone and mid-substance strains (30.4%±4.3% and 10.8%±2.4%, respectively) before failure than the other two regions (superior band: 20.8%±3.8% and 9.1%±2.8%, respectively; posterior axillary pouch: 25.2%±5.8% and 7.8%±2.6%, respectively). Bone-to-bone strain was always greater than mid-substance strain, indicating that when the IGHL is stretched, the tissue near the insertion sites will experience much greater strain than the tissue in the mid-substance. Insertion failures were more likely at slower strain rates, and ligamentous failures were predominant at the fast strain rate. When compared with other tensile studies of the IGHL at slower strain rates (0.01% per second and 0.1% per second), the superior band and the anterior axillary pouch demonstrated the viscoelastic effects of increased stiffness and failure stress. This superior band and anterior axillary pouch viscoelastic stiffening effect suggests that these two regions may function to restrain the humeral head from rapid abnormal anterior displacement in the clinically vulnerable position of abduction and external rotation.
Of 161 patients with 162 shoulders operated on during a thirty-year period (1946 to 1976), 124 were re-examined and twenty-one answered a questionnaire. The lesions found at surgery were separation of the capsule from the anterior glenoid rim in 85 per cent, a Hill-Sachs lesion of the humeral head in 77 per cent, and damage to the anterior glenoid rim (including fracture) in 73 per cent. There were five recurrences (3.5 per cent) after repair by the method described in the 145 shoulders that were followed. Only one of the forty-six patients with dislocation on the dominant side and one of the thirty-one with dislocation on the non-dominant side failed to return to the competitive athletic activities in which they participated prior to injury. The results at follow-up were rated excellent in 74 per cent, good in 23 per cent, and poor in 3 per cent. Ninety-eight per cent of the patients rated their result as excellent or good. Sixty-nine per cent of the shoulders had a full range of motion, and only 2 per cent of these shoulders redislocated. A fracture of the rim of the glenoid did not increase the risk of recurrence, while a moderate to severe Hill-Sachs lesion increased the risk only slightly. We concluded that with the meticulous technique of the Bankart repair as described, postoperative immobilization is not necessary, early return of motion and function can be expected, and resumption of athletic activities with no limitation of shoulder motion is possible for most patients.
The purpose of this study was to characterize the role of the capsule in the interval between the supraspinatus and subscapularis tendons with respect to glenohumeral motion, translation, and stability. We used a six-degrees-of-freedom position-sensor and a six-degrees-of-freedom force and torque-transducer to determine the glenohumoral rotations and translations that resulted from applied loads in eight cadaver shoulders. The range of motion of each specimen was measured with the capsule in the rotator interval in a normal state, after the capsule had been sectioned, and after it had been imbricated. Operative alteration of this capsular interval was found to affect flexion, extension, external rotation, and adduction of the humerus with respect to the scapula. Modification of this portion of the capsule also affected obligate anterior translation of the humeral head on the glenoid during flexion. Limitation of motion and obligate translation were increased by operative imbrication and diminished by sectioning of the rotator interval capsule. Passive stability of the glenohumeral joint was evaluated with the use of anterior, posterior, and inferior stress tests. Instability and occasional frank dislocation of the glenohumeral joint occurred inferiorly and posteriorly after section of the rotator interval capsule. Imbrication of this part of the capsule increased the resistance to inferior and posterior translation.
We studied the gross, histological, and vascular anatomy of the glenoid labrum in twenty-three fresh-frozen shoulders from cadavera to demonstrate its cross-sectional anatomy, its microvascularity, and its attachments. The superior and anterosuperior portions of the labrum are loosely attached to the glenoid, and the macro-anatomy of those portions is similar to that of the meniscus of the knee. The superior portion of the labrum also consistently inserts directly into the biceps tendon, while its inferior portion is firmly attached to the glenoid rim and appears as a fibrous, immobile extension of the articular cartilage. The arteries supplying the periphery of the glenoid labrum come from the suprascapular, circumflex scapular, and posterior circumflex humeral arteries. In general, the superior and anterosuperior parts of the labrum have less vascularity than do the posterosuperior and inferior parts, and the vascularity is limited to the periphery of the labrum. Vessels supplying the labrum originate from either capsular or periosteal vessels and not from the underlying bone.
The tensile properties of the inferior glenohumeral ligament have been determined in 16 freshly frozen cadaver shoulders. The inferior glenohumeral ligament was divided into three anatomical regions: a superior band, an anterior axillary pouch, and a posterior axillary pouch. This yielded 48 bone-ligament-bone specimens, which were tested to failure in uniaxial tension. The superior band was consistently the thickest region, averaging 2.79 mm. The thickness of the inferior glenohumeral ligament decreased from antero-superiorly to postero-inferiorly. The resting length of all three anatomical regions was not statistically different. Total specimen strain to failure for all bone-ligament-bone specimens averaged 27%. Variations occurred between the three regions, with the anterior pouch specimens failing at a higher strain (34%) than those from the superior band (24%) or the posterior pouch (23%). Strain to failure for the ligament midsubstance (11%) was found to be significantly less than that for the entire specimen (27%). Thus, larger strain must occur near the insertion sites of the inferior glenohumeral ligament. Stress at failure was found to be nearly identical for the three regions of the ligament, averaging 5.5 MPa. These values are lower than those reported for other soft tissues, such as the anterior cruciate ligament and patellar tendon. The anterior pouch was found to be less stiff than the other two regions, perhaps suggesting that it is composed of more highly crimped collagen fibers. Three failure sites were seen for the inferior glenohumeral ligament: the glenoid insertion (40%), the ligament substance (35%), and the humeral insertion (25%). In addition, significant capsular stretching occurred before failure, regardless of the failure mode.
Forty patients who had a diagnosis of multidirectional instability of forty-two shoulders had a modified Bankart operation in which a T-shaped incision was made in the anterior portion of the capsule, with advancement of the inferior flap superiorly and of the superior flap medially. All of the patients had been injured during athletic activities. Some degree of anterior labral injury was present in thirty-eight of the forty-two shoulders. Half of the patients had generalized ligamentous laxity. The patients were followed for an average of three years (range, two to seven years). Four patients had episodes of instability after the operation. Three had a single episode of posterior subluxation during throwing, one had recurrent posterior subluxation that subsequently was treated by posterior stabilization, and one had anterior subluxation while he was diving from a high board. The average loss of external rotation after the operation was 5 degrees with the arm at the side and 4 degrees with the arm abducted 90 degrees. Satisfaction of the patient was rated excellent for forty (95 per cent) of the shoulders, good for one shoulder, and fair for one shoulder. However, throwing athletes found that they were unable to throw a ball with as much speed as before the operation.
Thirty-one patients who were unable to abduct the involved arm after reduction of a primary anterior dislocation of the glenohumeral joint were found to have a ruptured rotator cuff. All of the patients were more than thirty-five years old. Twenty-nine of them were initially presumed to have had an injury to the axillary nerve, although this injury was confirmed in only four of the twenty patients who had electrodiagnostic studies. In eight patients, the subscapularis tendon and anterior part of the capsule had ruptured from the lesser tuberosity. Recurrent instability developed in all eight patients, and repair of these structures alone was successful in restoring stability. The association between primary anterior dislocation of the glenohumeral joint and rupture of the rotator cuff in the older patient who cannot abduct the arm after reduction is poorly appreciated, as it is often missed. In our series of such patients, the incidence of injury to the axillary nerve was 7.8 per cent, as compared with 100 per cent for rupture of the rotator cuff. However, the comparative rates of occurrence of these two entities in older patients who have an anterior dislocation have not been determined.
We analyzed the cases of 39 patients who were treated for recurrent anterior dislocation of the shoulder after unsuccessful surgical repair for the same condition in order to identify factors responsible for failure of the earlier operations and to determine the results of treatment of the post-surgical recurrence. The prior operations included 19 Bankart, 7 Putti-Platt, 5 Magnuson, 3 duToit, 2 Bristow, and 3 Nicola procedures. Thirty-two shoulders were treated by reoperation. At reoperation the most common pathological lesion associated with recurrence of the dislocation after the prior repair was a Bankart lesion (avulsion of the capsule and labrum from the anterior glenoid rim). This was present in 84% of the 32 shoulders that were treated by reoperation. Excessive laxity of the capsule was found in 83% of the 29 shoulders in which laxity was assessed, and was considered to be the primary cause of instability in 4 shoulders. A Hill-Sachs lesion of the humeral head was found in 76% of the 29 shoulders that were evaluated for this lesion and was large in 3 of the shoulders. Other factors that were associated with recurrent instability were scarring of the subscapularis muscle, generalized ligament laxity, technical errors at surgery, and severe reinjury. The success rate of reoperation after previous failure was very encouraging. Of the 24 shoulders that were reoperated on and were followed for 2 years or longer, 10 were graded excellent; 12, good; and 2, poor. One (4%) of the 24 shoulders that were reoperated on continued to dislocate and another shoulder continued to subluxate, making the incidence of recurrent instability after reoperation 8%. Seven of the 39 shoulders did not have a reoperation but were treated with specific resistive exercises. The results in these were 1 excellent, 4 good, 1 fair, and 1 poor. Eight patients were lost to follow-up.
Morgan recently reported excellent results by arthroscopically suturing detached labra to the glenoid via drill holes in anterior shoulder dislocators. We attempted to quantitatively compare the operative time, and perioperative morbidity employing this technique to these same parameters using the open Bankart procedure. We retrospectively reviewed the records of consecutive patients undergoing either of these procedures at our institution over the past 2 years. Only those cases wherein the labra were reattached to the glenoid via drill holes were considered. There were 20 patients in the arthroscopic and 18 in the open Bankart groups. Using the arthroscopic method, there was a 1.8-fold decrease in operative time, a 10-fold decrease in blood loss, and a 2.5-fold decrease in postoperative narcotic use compared with the open procedure (p < 0.001). Postoperative fevers were similarly reduced. Hospital stay averaged 3.1 days with the open procedure compared with 1.1 days with the arthroscopic method (p < 0.001). Most arthroscopic Bankarts are now performed on a same-day basis. Time lost from work was 25.5 and 15.3 days for the open and arthroscopic procedures, respectively (p < 0.001). There were three complications among the patients treated with the open technique compared with none in the arthroscopic group. Thus, we conclude that the arthroscopic Bankart procedure offers significant improvements in operative time, perioperative morbidity, and complications compared with the open technique for patients with anterior shoulder instability.
The purpose of this paper was to report our experience with an arthroscopic technique of repair for the Bankart lesion following shoulder instability. Twenty-seven patients (average age, 21.7 years) were followed for an average of 36 months after arthroscopic suture stabilization of anterior shoulder instability. Patients were excluded if instability was multidirectional or voluntary and if there was radiographic evidence of a significant loss of glenoid bone stock. Clinical evaluation using a functional grading system showed that 10 patients were rated as excellent, 5 good, and 12 poor. Fourteen patients returned to their previous level of activity. There were 12 patients rated as failed; all had recurrent instability of the shoulder. Success was associated with a period of immobilization of 3 weeks or longer and a history of acute injury, especially subluxation. Failures were associated with shorter immobilization periods after surgery and in patients who had recurrent dislocations. The younger patient, who may not have complied with the immobilization protocol, also seemed to be associated with failure. Contact sports seems to leave a patient at high risk for recurrence. We recommend caution in the use of arthroscopic procedures for the competitive athlete in whom a second surgery and rehabilitation might mean loss of more sports participation.
This article presents a different arthroscopic approach to the diagnosis and treatment of anterior shoulder instability. Surgical technique, the postoperative regimen, and the results and pitfalls of surgery using suture anchors are discussed.
Fifteen patients noted at surgery to have an isolated defect in the rotator interval and no other pathologic abnormality underwent closure of the defect as an isolated procedure for recurrent instability symptoms. Intraoperative assessment of each of these shoulders after the closure demonstrated adequate stability, and no other stabilization procedures were performed. The average age of the patients was 24 years, and 10 of the 15 patients were women. Examination under anesthesia revealed increased inferior translation in all patients, as illustrated by at least a 1+ sulcus sign. The rotator interval defect averaged 2.75 cm in width and 2.3 cm in height. The rotator interval defect edges were freshened and approximated (nine patients) or imbricated (six patients), depending on the anterior capsular laxity and the degree of glenohumeral joint translation possible. Followup averaged 3.3 years (range, 2.2 to 5.3), and all patients achieved either a good or excellent result using the American Shoulder and Elbow Surgeons evaluation scale and the Rowe rating scale. Although most patients with a defect in the rotator interval require a standard stabilization procedure as a supplement to closure of the defect, approximation or imbrication of the defect as an initial step at surgery may confer adequate stability in selected patients and obviate the need for formal capsular advancement.
The purpose of this study was to evaluate prospectively the arthroscopic findings of the unstable shoulder, to provide insights into the causes and mechanisms of shoulder instability, and to establish a rationale for using special surgical procedures. Arthroscopic examination was performed on 212 patients who had at least 1 documented shoulder dislocation. Of these 212 patients, 184 (87%) patients had anterior glenoid labral tears, 168 (79%) patients had ventral capsule insufficiency, 144 (68%) patients had Hill-Sachs compression fractures, 116 (55%) patients had glenohumeral ligament insufficiency, 30 (14%) patients had complete rotator cuff tendon tears, 26 (12%) patients had posterior glenoid labral tears, 14 (7%) patients had superior labrum anterior and inferior lesions. As this prospective study shows, multiple morphologic changes are associated with instability of the glenohumeral joint; there is no single cause for an unstable shoulder. Arthroscopic examination of the shoulder before surgery revealed a significant amount of information that would have been undetected without the aid of expensive diagnostic tools. For instance, the labrum and rim of the anteroinferior glenoid showed typical abnormalities corresponding to different entities of anterior instability.
The avulsion of the glenohumeral ligament labral complex at the glenoid (Bankart lesion), as well as ligamentous laxity are well known causes of anterior shoulder instability. A lesser known entity, the humeral avulsion of glenohumeral ligaments (HAGL), was studied to determine its incidence and its role in anterior glenohumeral instability. Sixty-four shoulders with the diagnosis of anterior instability were prospectively evaluated by arthroscopy for intraarticular pathology, including Bankart, capsular laxity, and HAGL lesions. Six shoulders were found to have HAGL lesions (9.3%), 11 shoulders with generalized capsular laxity (17.2%), and 47 shoulders with Bankart lesions (73.5%). In patients with documented anterior instability without a demonstratable "primary" Bankart lesion, a HAGL lesion should be ruled out. This lesion is readily recognized arthroscopically, and an appropriate repair of this lesion can restore anterior stability to the patient. The pathological anatomy of the HAGL lesion and our treatment of this lesion is discussed.
The acute management of the initial, anterior shoulder dislocation is dependent on the age and activity demands of the patient. After a thorough examination and appropriate radiographs, a gentle closed reduction is the initial treatment. Previous authors have recommended a period of immobilization followed by a rehabilitation program emphasizing rotator cuff strengthening. Restricting return to athletic activities to allow adequate soft tissue healing is also recommended. This will effectively treat the vast majority of patients with this injury. In patients older than 25 years of age, one would expect a relatively low recurrence rate, especially in patients with low activity demands or in patients willing to modify activity. In active, young patients desiring a return to strenuous activity, however, most studies and our own experience demonstrate high recurrence rates. In the authors' experience, the examination under anesthesia and arthroscopic evaluation have confirmed an avulsion of the anterior-inferior capsulolabral complex as the primary injury component. The special circumstances of an initial dislocation with a hemarthrosis and excellent tissue quality make it ideal for arthroscopic stabilization. Our early results are encouraging and we believe this approach is a viable option in the management of this common injury in young athletes. As arthroscopic techniques for glenohumeral instability improve, we would expect an improvement on these initial results. Acute operative stabilization for the initial anterior dislocation is considered for: (1) initial dislocation that requires a reduction; (2) a young, athletic, high demand patient (<25 years of age) who is unwilling to modify his lifestyle; (3) subjects with no prior shoulder subluxation or impingement history; (4) subjects with no neurologic injury; and (5) subjects with no greater tuberosity fracture.
We compared open and arthroscopic stabilizations of true Bankart lesions in patients with traumatic, unidirectional anterior glenohumeral dislocations. The 27 patients were men (age range, 18 to 56 years) who were involved in recreational sports. One group (15 patients) had elected an arthroscopic Bankart repair; the other group (12 patients) had chosen open stabilization with a standard deltopectoral approach. Patients were followed up 17 to 42 months after surgery by examination, radiographs, and interviews. In the open repair group, 1 of the 12 patients experienced a subluxation in the follow-up period, but no patients had dislocations or reoperations. In the arthroscopic group, 5 of 15 patients had experienced subluxation or dislocation; of these 5 patients, 2 underwent reoperation. The arthroscopic group had significantly worse results in satisfaction, stability, apprehension, and loss of forward flexion in the operated limb. In summary, the arthroscopic procedure did not significantly improve function; instead, it produced an increased failure rate compared with the open procedure. Therefore, we believe that open stabilization remains the procedure of choice for patients with true Bankart lesions.
The purpose of this study was to evaluate the effect of temperature on shrinkage and the histologic properties of glenohumeral joint capsular tissue. Six fresh-frozen cadaveric shoulders were used for this study. Seven joint capsule specimens were taken from different regions from each glenohumeral joint and assigned to one of seven treatment groups (37 degrees, 55 degrees, 60 degrees, 65 degrees, 70 degrees, 75 degrees, 80 degrees C) using a randomized block design. Specimens were placed in a tissue bath heated to one of the designated temperatures for 10 minutes. Specimens treated with temperatures at or above 65 degrees C experienced significant shrinkage compared with those treated with a 37 degrees C bath. The posttreatment lengths in the 70 degrees, 75 degrees, and 80 degrees C groups were significantly less than the pretreatment lengths. Histologic analysis revealed significant thermal alteration characterized by hyalinization of collagen in the 65 degrees, 70 degrees, 75 degrees, and 80 degrees C groups. This study demonstrated that temperatures at or above 65 degrees C caused significant shrinkage of glenohumeral joint capsular tissue. These results are consistent with histologic findings, which revealed significant thermal changes of collagen in the 65 degrees, 70 degrees, 75 degrees, and 80 degrees C groups. To verify the validity of laser application for shrinkage of joint capsule, studies designed to compare these findings with the effects of laser energy must be performed.
In this prospective study, 40 consecutive patients identified as high risk for recurrent instability were managed by an arthroscopic Bankart repair using nonabsorbable sutures and anchors. The technique employed is an arthroscopic modification of the capsulolabral repair described by Jobe. One-and-one-half to 3 years postoperatively (average 30 months), 37 of the 40 patients (93%) remained stable. The average Bankart score was 90. Thirty-seven of the 40 patients returned to normal activities, including sports, by 6 months postoperatively. Twenty-nine of the 32 patients involved in athletic activities returned to their respective sports at the same or higher level. Three patients had discontinued sporting activities due to graduation but felt as though they could resume their activities at the same level. Three patients developed recurrent instability, all of whom required surgical restabilization. Arthroscopic Bankart Repair using suture anchor technique in a high demand population provided results superior to those previously reported with the suture punch technique in our patient population. The results may be equivalent to open reconstruction in this high-risk patient population.
The purpose of this study was to compare patients with anterior shoulder instability who were treated with an open Bankart procedure with those treated with an arthroscopic procedure. During a 3-year period, 43 patients (44 shoulders) were surgically treated. Thirty-four patients were available for followup. Eighteen shoulders had open Bankart procedure, and 16 shoulders were treated arthroscopically. Capsular laxity can be better assessed with the open procedure. A Bankart lesion was found in all the patients in both series. Average followup for Group 1 was 34 months, and for Group 2, it was 23 months. Group 1 had 83% good to excellent results with no recurrent dislocation or reoperation. Group 2 had 50% good to excellent results, and 50% fair to poor results with 3 recurrent dislocations and 4 recurrent subluxations that required second operation. The average loss of external rotation in Group 1 was not significantly greater than that in Group 2. Sixteen patients in Group 1 and 8 patients in Group 2 were able to return to their primary work or sport. Results of arthroscopic Bankart repair do not equal those of the open Bankart procedure for the rate of recurrence and postoperative range of motion. The followup reported is short, and more dislocations can be anticipated with longer followup.
This study evaluated the effect of radiofrequency energy on the histological and ultrastructural appearance of joint capsular collagen. Femoropatellar joint capsular specimens from adult sheep were treated with one of three treatment temperatures (45 degrees C, 65 degrees C, and 85 degrees C) with a radiofrequency generator or served as control in a randomized block design. Twenty-four specimens (n = 6) were processed for histological examination as well as ultrastructural analysis using transmission electron microscopy. A computer-based area determination program was used to calculate the area affected in histological samples. Histological changes consisted of thermal tissue damage characterized by collagen fiber fusion and fibroblastic nuclear pyknosis at all application temperatures with clear demarcations between treated and untreated tissue. Mean tissue affected ranged from 50.4% for 85 degrees C to 22.5% for 45 degrees C. There was a strong correlation between treatment temperature and percent area affected (P < .001, R2 = .65). Ultrastructural alterations included a general increase in cross-sectional fibril diameter and loss of fibril size variation with increasing treatment temperature. Longitudinal sections of collagen fibrils showed increased fibril diameter and the loss of cross-striations in the treated groups. Thermally induced ultrastructural collagen fibril alteration is likely the predominant mechanism of tissue shrinkage caused by application of radiofrequency energy.
Rotator interval tear is one of the lesions identified in patients with glenohumeral instability. We present our technique for arthroscopic repair that eliminates entry into the subacromial space and allows the surgeon to suture the rotator interval under direct intra-articular vision.
The purpose of this study was to evaluate the results of an arthroscopic transglenoid suture-stabilization procedure in athletically active patients who had recurrent, unilateral, unidirectional anterior dislocations of the shoulder and an isolated anterior detachment of the glenoid labrum.
Forty-one patients who had unilateral, unidirectional anterior dislocations of the shoulder and an isolated anterior detachment of the glenoid labrum were managed with arthroscopic repair. All patients were athletic, and seventeen of the male patients were football players. No patient had inferior or posterior laxity or a posterior detachment. The sutures were anchored to the posterior aspect of the scapula, and the knots were tied anteriorly to secure the detached region of the labrum and the inferior glenohumeral ligament to the anterior aspect of the scapula. The mean duration of follow-up was fifty-two months (range, twenty-five months to seven years). The patients were evaluated annually with a physical examination, radiographs, isokinetic strength-testing, the modified shoulder-rating scale of Rowe and Zarins, and the scoring system of the American Shoulder and Elbow Surgeons.
Forty (98 percent) of the forty-one athletes returned to their preoperative sport postoperatively. Thirty-nine patients (95 percent) had no additional dislocations or subluxations, and two (5 percent), both of whom were football players, had a single episode of subluxation. Thirty-seven patients (90 percent) had a score of at least 80 points on the scale of Rowe and Zarins, and thirty-four (83 percent) had a score of at least 90 points. Thirty-nine patients (95 percent) had a score of at least 80 points on the scale of the American Shoulder and Elbow Surgeons, and twenty-five (61 percent) had a score of at least 90 points. Lower scores were associated with loose bodies seen on arthroscopy (p = 0.001), osseous lesions seen on postoperative radiographs (p = 0.036), and subluxation (p = 0.000). Twenty-two shoulders (54 percent) had a full range of motion in all planes, and eighteen (44 percent) had no strength deficit in any position on isokinetic testing. With the numbers available for study, no significant association was found between the presence of a Hill-Sachs or an osseous Bankart lesion on preoperative radiographs and the overall score on the scale of Rowe and Zarins or the scale of the American Shoulder and Elbow Surgeons; however, there was a significant association between the range of motion and an osseous Bankart lesion on preoperative radiographs (p = 0.002) and between decreased strength on isokinetic testing and a Hill-Sachs lesion on preoperative radiographs and an osseous lesion on postoperative radiographs (p = 0.022). There also was a significant association between a decreased range of motion (p < 0.002) and decreased strength (p = 0.014) and the arthroscopic finding of loose bodies. Muscle strength also was affected by arm dominance and the number of preoperative dislocations.
Arthroscopic transglenoid repair of isolated anterior labral detachments restored stability of the shoulder and led to a favorable outcome in thirty-nine (95 percent) of the forty-one athletes. Only the two football players who had postoperative subluxation had a score of less than 80 points according to the scale of the American Shoulder and Elbow Surgeons.
The author has previously elucidated and advocated various biomechanical principles for application in rotator cuff repair. This article is an attempt to link all these concepts together into a unified stepwise approach to arthroscopic rotator cuff repair that will maximize the strength of the repair for all tear configurations.
The arthroscopic management of patients with shoulder instability continues to evolve. The obvious benefits include a reduction of operative time, preservation of the subscapularis, improved visualization, and less blood loss. Newer techniques that allow the plastic deformation of the IGHLC to be addressed are emerging, which may yield results as successful as those of open Bankart repair. The ability to adequately tension the IGHLC may result in some loss of external rotation, which may improve results. Capsular tensioning must be critically analyzed at the time of surgery. Adequate stabilization with an arthroscopic approach should provide a convincing postoperative examination of stability. A careful examination after suture placement may indicate residual laxity that must be addressed. Finally, periods of immobilization are similar in open and arthroscopic techniques. The process of biologic healing is not accelerated by arthroscopic techniques, and early return to sport activities that may endanger the repair will likely result in early failure.
Techniques for the arthroscopic treatment of patients with recurrent shoulder instability have flourished despite several early reports indicating greater failure rates compared with traditional open stabilization techniques. Proponents of arthroscopic stabilization cite its advantages as including more accurate identification of intra-articular pathology, less morbidity, improved cosmesis, faster recovery, and, possibly, greater returns in postoperative motion. Disadvantages include complications inherent to the technique applied, requisite technical skill, a potential lack of versatility to treat a spectrum of pathology, and generally higher failure rates. As the knowledge of the basic science behind the pathophysiology of shoulder instability improves and as more clinical reports emerge, the exact indications for arthroscopic stabilization are gradually being refined. Techniques for the arthroscopic stabilization treatment of patients with recurrent shoulder instability have flourished despite several early reports indicating greater failure rates compared with traditional open stabilization techniques. Proponents cite advantages including more accurate identification of intra-articular pathology, less morbidity, improved cosmesis, faster recovery, and, possibly, greater return of postoperative motion. Disadvantages include complications inherent to the applied techniques, requisite technical skill, a potential lack of versatility to treat a spectrum of pathology, and generally higher failure rates. As knowledge of the basic science of the pathophysiology of shoulder instability improves, and as more clinical reports emerge, the exact indications for arthroscopic stabilization gradually are being refined.
Previous studies on arthroscopic treatment of anterior-inferior glenohumeral instability have focused on the repair of lesions of the anterior-inferior aspect of the labrum (Bankart lesions) and have demonstrated failure rates of as high as 50 percent. The current investigation supports the concept that anterior-inferior instability is associated with multiple lesions and that success rates can be increased by treating all of the lesions at the time of the operation. We present the results of arthroscopic treatment of anterior-inferior gleno-humeral instability after a minimum duration of followup of two years.
The study group consisted of fifty-three patients who had a mean age of thirty-two years (range, fifteen to fifty-eight years) at the time of the operation. There were forty-four male and nine female patients. The mean interval from the time of the operation to the final follow-up evaluation was thirty-three months (range, twenty-six to sixty-three months). The scores on the American Shoulder and Elbow Surgeons (ASES) Shoulder Index and the rating systems of Constant and Murley, Rowe et al., and the University of California at Los Angeles (UCLA) were recorded preoperatively and at the time of the final follow-up.
Preoperatively, none of the patients had an overall rating of good or excellent according to the system of Rowe et al.; however, 92 percent (forty-nine) of the fifty-three patients had a rating of good or excellent at the time of the final follow-up. The mean score improved from 45.5 points to 91.7 points on the ASES Shoulder Index, from 56.4 points to 91.8 points with the system of Constant and Murley, from 11.3 points to 91.9 points with the system of Rowe et al., and from 17.6 points to 32.0 points according to the UCLA Shoulder Score (p = 0.001 for all comparisons). The mean passive external rotation with the shoulder in 90 degrees of abduction measured 88.2 degrees. Thirty-four of thirty-eight patients returned to their desired level of sports activity following the operation. Four patients who had persistent instability were considered to have had a failure of the index operation, and one of them had a second operative procedure.
The results of the present study suggest that our technique of arthroscopic treatment of anterior-inferior glenohumeral instability is better than previous arthroscopic techniques and is equivalent to open repair. We believe that the improved rate of success demonstrated in the present study was the result of repair not only of the anterior-inferior (Bankart) lesion but also (where necessary) of inferior and superior labral tears. Additionally, soft-tissue tension within the capsule and ligaments was corrected with use of a suture technique but was supplemented by laser thermal capsulorrhaphy in forty-eight of the fifty-three shoulders. Rotator interval repair was considered a critical factor in fourteen of the fifty-three shoulders.
Sixty-three consecutive patients with recurrent traumatic anterior shoulder instability underwent operative repair. The decision to select either arthroscopic Bankart repair or open capsular shift was based on the findings of an examination under anesthesia and the findings at the time of arthroscopy. Thirty-nine patients with only anterior translation on examination under anesthesia and a discrete Bankart lesion underwent arthroscopic Bankart repair with use of absorbable transfixing implants. Twenty-four patients with inferior translation in addition to anterior translation on examination under anesthesia and capsular laxity or injury on arthroscopy underwent an open capsular shift.
Treatment outcomes for each group were determined according to the scoring systems of Rowe et al., the American Shoulder and Elbow Surgeons, and the Short Form-36. Failure was defined as recurrence of dislocation or subluxation or the finding of apprehension. Fifty-nine (94 percent) of the sixty-three patients were examined and filled out a questionnaire at a mean of fifty-four months (range, twenty-seven to seventy-two months) following surgery.
There were no significant differences between the two groups with regard to the prevalence of failure or any of the other measured parameters of outcome. An unsatisfactory outcome occurred after nine (24 percent) of thirty-seven arthroscopic repairs and after four (18 percent) of twenty-two open reconstructions. All cases of recurrent instability resulted from a reinjury in a contact sport or a fall less than two years postoperatively. The treatment groups did not differ with regard to patient age, hand dominance, mechanism of initial injury, duration of follow-up, or delay until surgery. Measured losses of motion were minimal and, with the exception of forward elevation, slightly more of which was lost after the open capsular shifts (p = 0.05), did not differ between the two forms of treatment. Approximately 75 percent of the patients in each group returned to their favorite recreational sports with no or mild limitations. As rated by the patients, the result was good or excellent after thirty-one (84 percent) of the arthroscopic procedures and after twenty (91 percent) of the open procedures.
Arthroscopic and open repair techniques for the treatment of recurrent traumatic shoulder instability yield comparable results if the procedure is selected on the basis of the pathological findings at the time of surgery.
Forty-seven rotator interval regions from fetuses and 10 fresh-frozen rotator interval regions from adult cadavers were evaluated by gross dissection and light microscopy. Specimens from adults also were evaluated with ultrasound and magnetic resonance imaging. An analysis of 37 fetal specimens (> 14 weeks gestation) revealed two rotator interval types: Type I (9 of 37) was defined by a contiguous bridge of capsule consisting of poorly organized collagen fibers. A Type II rotator interval (28 of 37) had a complete defect covered by only a thin layer of synovium. Similar to the Type II rotator interval in the fetus, a rotator interval defect was present in six of eight specimens from adults. Histologically, the capsular tissue within the rotator interval consisted of poorly organized collagen fibers in specimens from the fetus and adult. Maximal opening of the rotator interval was seen by ultrasound with internal rotation and downward traction of the hyperextended arm in the coronal, oblique, and sagittal planes. Magnetic resonance imaging of the rotator interval region permitted anatomic evaluation. The complete absence of tissue in 28 of 37 fetuses suggests that the rotator interval defect is congenital. The authors recommend that surgeons carefully evaluate the integrity of the tissue within the rotator interval. When rotator interval closure is desired such as in patients with a persistent sulcus sign after arthroscopic stabilization, suturing the edges of more substantial tissue immediately adjacent to the boundaries of the rotator interval region would seem prudent.
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