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Recurrences after the open Bankart repair: A potential risk with use of suture anchors
Abstract
Eighty-seven consecutive patients were treated with an open Bankart repair for traumatic, recurrent anterior instability of the shoulder. Forty-six of these patients underwent a transosseous suture technique. Forty-one patients were operated on with suture anchors. After follow-ups that ranged from 18 to 85 months, 7 of the 87 patients showed signs of recurrence and another 14 patients reported apprehension. Compared with the 66 patients without residual instability, these 21 patients were more likely to have been operated on with suture anchors (P < .05), had a greater incidence of hypermobility in joints other than the shoulder (P < .05), and had had a greater number of preoperative episodes (P < .05). In light of this data we recommend the transosseous suture technique for open Bankart repairs. In addition, a cautious and extensive capsular repair may be required when a patient reports frequent subluxations preoperatively or has hypermobility in some joints, if not in the shoulder per se.
... Three studies were of high quality and 14 were of intermediate quality. Two studies (by Tamali et al. [28] and Pogorzelski et al. [29]) were of low quality but had clearly defined follow-up durations ( Table 2). ...
... Four studies [16,20,21,28] presented information regarding side dominance of the shoulder with recurrent instability. Pooled data showed that recurrent instability after a Bankart procedure was less common on the dominant side than on the non-dominant side Table 6). ...
... Four studies [11,24,28,30] provided information on the relationship between shoulder hyperlaxity and recurrent instability. Pooled data showed that patients with shoulder hyperlaxity had a higher rate of recurrent instability than those who did not (28.7% ...
Abstract Background The aim of this literature review was to identify preoperative risk factors associated with recurrent instability after Bankart repair. Methods The PubMed, Web of Science, Embase, and Cochrane Library databases were searched for potentially eligible articles. Two reviewers independently screened the titles and abstracts using prespecified criteria. Articles were included if they clearly stated the risk factors for recurrence after Bankart repair. Data on patient characteristics and recurrence rate were collected from each study. A random-effects model was used for the meta-analysis and the statistical analysis was performed using Review Manager 5.4 software. Results Nineteen studies that included 2922 participants met the inclusion criteria. The overall pooled prevalence of recurrent instability was 15.3% (range 6.9–42). The mean follow-up duration was 40.5 months (18–108). Twenty-one risk factors were identified, 10 of which were explored quantitatively. Statistically significant risk factors for recurrent instability following a Bankart procedure were age under 20 years (odds ratio [OR] 4.24, 95% confidence interval [CI] 2.8–96.23, p
... 2. Öppen Bankartoperation i original är bästa operationsmetoden vid recidiverande främre axelledsluxation (Rowe et al 1978, Tomai et al 1999. ...
... ursprunget. Metoden i originalutförande ger ca tre procent recidiv(Rowe et al 1978, Hovelius et al 1979, Hovelius et al 2001, Tomai et al 1999, Bankart 1938, Gill et al 1997 och får anses som den absolut bästa (Konsensusrapport 1998). De modifikationer som gjorts, där metoden förenklats med hjälp av diverse ankare etc. har inte fungerat lika bra, undantaget bl a Pagnani och Domes publikation (2002), utan recidiven har postoperativt rapporterats till 10 procent eller mer(Karlsson et al 1995, Magnusson et al 2002, Norlin 1994, Tomai et al 1999, Kjeldsen et al 1996, Ungerbäck et al 1995. ...
... Metoden i originalutförande ger ca tre procent recidiv(Rowe et al 1978, Hovelius et al 1979, Hovelius et al 2001, Tomai et al 1999, Bankart 1938, Gill et al 1997 och får anses som den absolut bästa (Konsensusrapport 1998). De modifikationer som gjorts, där metoden förenklats med hjälp av diverse ankare etc. har inte fungerat lika bra, undantaget bl a Pagnani och Domes publikation (2002), utan recidiven har postoperativt rapporterats till 10 procent eller mer(Karlsson et al 1995, Magnusson et al 2002, Norlin 1994, Tomai et al 1999, Kjeldsen et al 1996, Ungerbäck et al 1995. Det förefaller också som om de redovisade resultaten med öppna metoder försämrats sedan de börjat jämföras med artroskopiska stabiliseringar.1948 ...
Nationellt Kompetenscentrum för Ortopedi (NKO) fick i juni 2005 i uppdrag från Sveriges
Kommuner och Landsting (SKL) att utarbeta nationella medicinska indikationer för axelkirurgi.
Bakgrunden till uppdraget är den vårdgaranti som infördes Sverige den 1 november
2005 och som innebär att beslutad behandling ska erbjudas patienterna inom 90 dagar. Tidigare
har NKO arbetet med att utarbeta nationella medicinska indikationer för operation av höftoch
knäledsartros, operation av diskbråck, spinal stenos och segmentell ryggsmärta samt operation
av menisk- och korsbandsskador. Detta arbete avrapporterades i mars 2005 och finns
att läsa om på www.nko.se eller www.skl.se
I axelgruppens uppdrag ingår att beskriva evidens inom tre områden: 1) subacromiella smärttillstånd,
2) axelinstabilitet och 3) glenohumeral atros/artrit, samt komma med förslag till nationella
medicinska indikationer för respektive sjukdomsområde, ge en nulägesbeskrivning
avseende sjukskrivning och väntetider samt göra en inventering av antal utförda axeloperationer
i både öppen och sluten vård inklusive privat verksamhet för hela landet samt ge förslag
till remiss- och bedömningsmall.
Smärtor i axlar och skuldror är vanligt förekommande. Uppskattningsvis lider 1,7 miljoner
svenskar av ömmande axlar och nacke. Förutom smärta, värk och funktionsnedsättning förorsakar
dessa sjukdomstillstånd inte sällan sjukskrivning under kortare eller längre period. För
vissa personer med smärttillstånd i axlarna räcker det med adekvat fysioterapi för att komma
till rätta med problemen medan andra behöver operativ behandling.
De axelåkommor som kräver operativ behandling tillhör i merparten av fallen någon av de tre
diagnosgrupperna: subacromiella smärttillstånd, axelinstabilitet eller glenohumeral
artros/artrit. Denna rapport visar att det årligen i landet utför ca 6 500 operationer till följd av
dessa diagnoser. Vidare framgår att kökvoten för dessa sjukdomsgrupper motsvarar en genomsnittlig
väntetid på 3-6 månader, vilket är i paritet med den genomsnittliga kökvoten som
tidigare redovisats för höft- och knäledsplastiker, diskbråck, artroskopi i knäled och korsbandsoperationer
(NKO 2005). När det gäller sjukskrivning visar rapporten på svårigheterna
med att få fram användbar statistik. Den statistik som vi redovisar omfattar endast sjukfall
som har en specifik axeldiagnos. Emellertid finns det en rad ortopediska diagnoskoder där
axelkirurgiska diagnoser kan ingå, med dessa sjukfall är, med dagens system för uppföljning
av sjukfall efter sjukskrivningsorsak, inte möjliga att särskilja.
Vid elektiv axelkirurgi är indikationerna för kirurgi i stort desamma som för andra ortopediska
diagnoser såsom artros i höft- och knäled. De påtagligaste indikationerna är vilovärk, nattlig
smärta och rörelsesmärta med funktionsinskränkningar. I rapporten presenteras förslag till
remismall och bedömningsmall. Arbetsgruppen har under sitt arbete funnit att väl evidensbaserade
indikationer för axelkirurgi i regel finns, men att flera framförallt prospektiva randomiserade
studier givetvis skulle kunna bringa ytterligare klarhet i handläggningen. När det gäller
axelartroplastikverksamheten finns sedan flera år SSAS axelartroplastikregister där protesoperationerna
i landet registreras och följs upp. Detta ska förhoppningsvis borga för en väl evidensbaserad
verksamhet.
Axelgruppens arbete kan förhoppningsvis bidra till att gemensamma behandlingsindikationer
används. En standardiserad remisshantering bör dessutom underlätta planeringen av verksamheten.
Avancerade axelingrepp eller verksamhet av mindre volym bör i syfte att höja kvaliteten
koncentreras till enheter där stor axelkirurgisk kompetens finns.
... Additional studies have demonstrated similarly low failure rates of 2% to 5%. 13,18,21 The use of suture anchors to repair the labrum to the glenoid was introduced in the early 1990s to reduce the time and difficulty associated with creating osseous tunnels. Arthroscopic stabilization has been greatly facilitated by suture anchor techniques and has become the preferred method of treatment for most orthopaedic surgeons. ...
... However, the mid-to long-term failure rates for modern arthroscopic Bankart repair with suture anchors have been reported to be from 4% to 18% in studies published in the past decade. 4,5,11,22,23 When comparing open Bankart repair techniques, Tamai et al 21 found that repair with bone tunnels has resulted in significantly lower dislocation rates compared with a repair with suture anchors. At 17-year follow-up, Hovelius et al 7 showed a difference in revision for instability of 0% for open bone tunnel Bankart repair versus 7% for open suture anchor repair. ...
Background:
Traditional Bankart repair using bone tunnels has a reported failure rate between 0% and 5% in long-term studies. Arthroscopic Bankart repair using suture anchors has become more popular; however, reported failure rates have been cited between 4% and 18%. There have been no satisfactory explanations for the differences in these outcomes.
Hypothesis:
Bone tunnels will provide increased coverage of the native labral footprint and demonstrate greater load to failure and stiffness and decreased cyclic displacement in biomechanical testing.
Study design:
Controlled laboratory study.
Methods:
Twenty-two fresh-frozen cadaveric shoulders were used. For footprint analysis, the labral footprint area was marked and measured using a Microscribe technique in 6 specimens. A 3-suture anchor repair was performed, and the area of the uncovered footprint was measured. This was repeated with traditional bone tunnel repair. For the biomechanical analysis, 8 paired specimens were randomly assigned to bone tunnel or suture anchor repair with the contralateral specimen assigned to the other technique. Each specimen underwent cyclic loading (5-25 N, 1 Hz, 100 cycles) and load to failure (15 mm/min). Displacement was measured using a digitized video recording system.
Results:
Bankart repair with bone tunnels provided significantly more coverage of the native labral footprint than repair with suture anchors (100% vs 27%, P < .001). Repair with bone tunnels (21.9 ± 8.7 N/mm) showed significantly greater stiffness than suture anchor repair (17.1 ± 3.5 N/mm, P = .032). Mean load to failure and gap formation after cyclic loading were not statistically different between bone tunnel (259 ± 76.8 N, 0.209 ± 0.064 mm) and suture anchor repairs (221.5 ± 59.0 N [P = .071], 0.161 ± 0.51 mm [P = .100]).
Conclusion:
Bankart repair with bone tunnels completely covered the footprint anatomy while suture anchor repair covered less than 30% of the native footprint. Repair using bone tunnels resulted in significantly greater stiffness than repair with suture anchors. Load to failure and gap formation were not significantly different.
... A score of twelve represents a patient with the least amount of difficulties and a score of 60 indicates a patient with the most disabilities. Outcomes were classified as excellent (12)(13)(14)(15)(16)(17)(18)(19)(20), good (21-30), fair (31-40) and a poor (41-60). ...
... All 96 articles were individually reviewed by 2 reviewers, resulting in 29 articles that met the inclusion criteria and were included in this report ( Figure 1). [2][3][4][5][7][8][9][10][11][12][13][14][15][16][17][18][19][20][22][23][24][25][26][27][28][29][30][31][32][33] Study Characteristics ...
Background:
Results of open Bankart repair have been well reported. However, less information is available outlining the timetable for return to play (RTP) in athletes after this procedure.
Purpose:
To review the current literature regarding (1) the timetable recommended for athletes to RTP after an open Bankart repair and (2) the objective criteria on which the decision to allow an athlete to RTP is based.
Study Design:
Systematic review; Level of evidence, 4.
Methods:
A comprehensive literature search was conducted of all relevant English-language articles using the electronic databases OVID and PubMed between the years 1947 and 2012 to identify open Bankart repair. Two reviewers screened articles for eligibility based on the following criteria: (1) an open Bankart repair, (2) a minimum follow-up of at least 8 months, (3) any report that described the procedure in athletes, and (4) any report that described the time for an athlete to RTP. All relevant data were collected and analyzed with regard to number of patients; mean follow-up; Rowe, Constant, and American Shoulder and Elbow (ASES) scores; redislocation rate; and return-to-sport timing.
Results:
In all, 559 relevant citations were identified, of which 29 articles met the inclusion criteria. The mean follow-up was 51.7 months (range, 8-162 months), and the mean age was 25.9 years (range, 21-31 years). The average Rowe score for all studies was 86.9 (range, 63-90). The average redislocation rate was 5.3%. Twenty-six of 29 studies cited a specific timetable for unrestricted RTP, with an average of 23.2 weeks (range, 12-36 weeks). Only 38% of authors reported sport-specific criteria for return to competition, with the majority allowing return to noncontact sports at 12 to 16 weeks, and the resumption of throwing/contact sports by 24 weeks. Three reports described specific functional parameters for RTP.
Conclusion:
The current review summarized return-to-play guidelines for athletic competition after open Bankart repair. These data may provide general guidelines to aid surgeons when determining the appropriate timetable to allow an athlete to return to unrestricted competition.
... Although suture anchors have been shown to provide equivalent or superior results for the treatment of labral and capsulolabral pathology, some authors have found greater rates of failure and continue to advocate transosseous suture fixation techniques. 24,25 Preparation of the glenoid surface and mobilization of the capsulolabral structures is critical with these procedures for the generation of a healthy bleeding bony bed to maximize healing potential. 26 In preparing the glenoid rim for anchor placement, however, the surgeon must exercise caution when decorticating so as not to compromise anchor purchase. ...
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.
... 11 Its fibres are arranged in a predominantly circumferential pattern although a superficial randomly arranged layer and a deep layer organised into dense insertional fibre bundles can be discerned on electron microscopy. 12,13 The labrum, as well as forming an origin for the glenohumeral ligaments and biceps anchor, also provides a static role in gleno-humeral stability. It deepens the socket by up to 50% leading some authors to attribute to it a ''chock block'' function, limiting humeral translation. ...
In part 1 of this article we have described the history of shoulder arthroscopy and its current indications. We introduced concepts useful in the execution and interpretation of shoulder arthroscopy and introduced some technical tips to help those starting out, or developing their expertise, in this surgical skill. In part 2 we will focus on the range of findings that arthroscopy can yield, which can at first be daunting and confusing. The spectrum of normal findings is quite wide and substantial experience is needed simply to recognise what is within this spectrum and what should be considered pathological. Furthermore some pathological findings can be subtle or obscure, and easily missed if the arthroscopy is not complete and correlated carefully with the examination under anaesthesia.
... In both of these studies, the capsulolabral complex was fixed to the glenoid with sutures through drill holes. Tamai et al. (1999) performed Bankart repairs using either trans-osseous fixation or with suture anchors, and found a higher risk of redislocation when anchors were used. In a retrospective study comparing the Putti-Platt procedure to a classic Bankart suture, Varmarken and Jensen (1989) found a redislocation rate of 13% in the Bankart group at the 4-year follow-up as compared to 22% in the Putti-Platt group. ...
This randomized study compared clinical results after surgery for posttraumatic shoulder instability with either an anatomical repair or an older, less anatomical but commonly used method. The less anatomical procedure has been considered quicker and less demanding, but it has been questioned regarding the clinical result. We therefore wanted to compare the clinical outcome of the two different procedures. Our hypothesis was that the anatomical repair would give less residual impairment postoperatively.
Patients with anterior posttraumatic shoulder instability were consecutively randomized on the day before surgery to either a Bankart repair using Mitek GI/GII anchors combined with capsular imbrication (B) (n = 33) or a Putti-Platt procedure (P) (n = 33). Follow-up was performed by examination at 2 years and using a self-evaluation score at 10 years.
At the 2-year follow-up, we found no difference in muscle strength between patients treated with the two surgical methods and there were no statistically significant differences in the Rowe scores (mean 90 units for both groups). Compared to preoperatively, the decrease in external rotation 2 years after surgery was 10 degrees in the P group and 3 degrees in the B group (p = 0.03). 10 years after surgery, 62 of 66 patients replied to a questionnaire sent by mail. It included a self-evaluating quality of life score for shoulder instability (WOSI) for evaluation of their shoulder function. In the P group 15 patients and in the B group 19 patients reported they had experienced either a redislocation or a subluxation with a new feeling of shoulder instability. Mean WOSI score was similar in the P and B groups: 80% and 83%, respectively. The WOSI score was 87% for patients with stable shoulders (n = 28) and 77% for those with unstable shoulders (n= 34) (p = 0.005).
With assessment of pain and general shoulder function, only a small difference was found between the two methods. The WOSI scores for stable shoulders indicated that some shoulders still had impaired function even though the shoulders had become stable.
... 7 In the early 1990s, the most common complication of suture anchor use noted was higher recurrence rates than are found with transosseous stabilization. 8,9 When the indications are followed appropriately, arthroscopic Bankart repair using suture anchors has a high success rate, comparable to the rate with open procedures. However, complications can arise from the use of suture anchors, including misplacement, loosening, disengagement, migration, osteolysis around bioabsorbable anchors, and anchor breakage. ...
The knotless anchor is a new type of suture anchor that eliminates the need to perform arthroscopic knots, thus facilitating the performance of arthroscopic shoulder surgery. We report our experience in the use of this type of anchor in arthroscopic Bankart repair and discuss a complication related to using this type of fixation device.
... Tamai ve ark. [33] 87 aç›k Bankart tamirinde 46 omuzda transosseöz dikifl, 41 omuzda dikifl ankoru kulland›klar›n›; transosseöz dikiflle daha iyi stabilite sa¤land›¤›n›, dikifl ankoru kullan›lan hastalarda anlaml› derecede fazla yetmezlik geliflti¤ini bildirmifllerdir. ...
A successful surgical intervention to restore glenohumeral stability should be based on the detection of all the problems and on a plan to correct all those that are reparable. Contribution of arthroscopy to better understand the pathological anatomy and to evaluate coexisting intra-articular problems, and advances in imaging modalities and in implant technology have increased the success rates and decreased complications. The best way to avoid complications is to gather all the relevant data preoperatively and during surgery to draw the correct diagnosis and to employ the most appropriate approach or approaches accordingly. Complication rates are lower with open surgical techniques, where problems mainly arise from limited joint movements, implant deficiency, and degenerative changes. Although arthroscopic surgery is associated with significantly fewer complications seen with open techniques, it results in higher recurrence rates. Revision surgery for stabilization of the shoulder should be directed to well-defined pathologies using appropriate techniques. The most common complication encountered is the recurrence of instability, which should primarily be dealt with by open surgical techniques.
... Tamai ve ark. [33] 87 aç›k Bankart tamirinde 46 omuzda transosseöz dikifl, 41 omuzda dikifl ankoru kulland›klar›n›; transosseöz dikiflle daha iyi stabilite sa¤land›¤›n›, dikifl ankoru kullan›lan hastalarda anlaml› derecede fazla yetmezlik geliflti¤ini bildirmifllerdir. ...
The basic principals of rehabilitation for shoulder stabilization are the restoration of glenohumeral compression stability, scapulohumeral motion synchrony, and the proprioceptive mechanism. The principals of rehabilitation applied following surgical treatment of patients with shoulder instability do not differ from those applied for non-operative patients. Recent advances in surgical techniques and suture materials have improved the quality of healing tissues and allowed early institution and acceleration of rehabilitation programs. There are many different rehabilitation protocols constructed according to the type of instability and surgical procedures, but when a postoperative rehabilitation program is outlined, the patient's age, previous activity level, expectations, and compliance with and response to treatment should also be taken into consideration.
Shoulder instability in hypermobile Ehlers-Danlos syndrome can result in lifelong pain and functional disability. Treatment in this population is complicated by the severe degree of instability as well as the underlying abnormalities of the joint connective tissue. Appropriate care for these patients requires a thorough understanding of the natural history of their disease, knowledge of the available treatment options and certain special considerations. This article reviews the pathoanatomy, recognition, and management of shoulder instability in the patient with hypermobile Ehlers-Danlos syndrome.
Introduction: The aim of this study is to compare the outcomes of surgical management after primary anterior shoulder dislocation to the outcomes of patients who have surgical stabilization after recurrent anterior shoulder instability.
Methods: A Medline (PubMed) search was performed in November of 2016 using the following key terms: shoulder, labrum, Bankart, instability, repair, outcome, recurrent. In May 2017 a Cochrane search was performed using similar key terms to ensure we included all studies. Only level I and II studies were included.
Results: There were three studies that compared primary repair to delayed repair. In all three studies, the rate of recurrence was higher in group R than group S. When pooled, there was not a statistically sig- nificant difference between these groups, but there was a slightly higher odds of recurrence in group R (pooled OR 2.08, CI 0.69e6.26, p 1⁄4 0.19). No significant differences were appreciated in functional out- comes or complications in these two groups.
Conclusion: Further level I and level II studies to compare surgical treatment after first time and recurrent instability are needed. This study failed to find a statistically significant difference in recurrence rates in patients who had stabilization acutely after a single episode compared to patients with recurrent instability events, although results suggest there may be a small benefit in primary stabilization.
Management of the unstable shoulder after a failed stabilization procedure can be difficult and challenging. We need a deep and detailed understanding of the shoulder anatomy and its restraints to determine the origin of the patient’s primary pathology. Key factors for shoulder stabilization surgery are an adequate patient selection, precise surgical technique selection and fulfillment, identification and correction of anatomy abnormalities, and integration of patient and surgeon expectation. When any of these requirements fail, our surgery can fail too. It is important to identify why the initial procedure failed and perform a meticulous evaluation of the patient: background of trauma and detailed patient’s history, a complete physical exam, and imaging.
In 2004, we developed a new type of arthroscopic Bankart repair technique named the double anchor footprint fixation (DAFF), using two different suture anchors for the glenoid neck and glenoid surface anchors, to achieve a more anatomic and wider footprint fixation. As soon as the small, all-suture soft anchor was available in 2011, the twin anchor footprint fixation (TAFF) technique was developed using only the soft anchor for both the glenoid neck and glenoid surface anchors. This TAFF technique might be suitably indicated for patients with a significant ALPSA (anterior labro ligamentous periosteal sleeve avulsion) lesion or those who need capsular shift. Moreover, the specific indications of this technique are revision cases after conventional arthroscopic Bankart repair surgery, and a bony Bankart lesion with large thick bone fragments. The TAFF technique using the all-suture soft anchors is a step closer to a true transosseous suture technique, which is the conventional open procedure making a bone tunnel.
Purpose: This paper analyzes the results of arthroscopic bankart repair for anterior recurrent dislocation following a trauma on shoulder. Material and Methods: The subjects were twenty-three (23) cases that were available to follow up for more than eighteen months during the period from November 2001 to June 2003 and were chosen from patients to whom arthroscopic bankart repair was applied using a knotless suture anchor for their traumatic anterior recurrent dislocation on the shoulder. Their average age was 28 (ranging from 15 to 60) with 20 males and 3 females. The injury from sports activities accounted for the most cases with 14 subjects. The average follow-up period was 27 months (ranging from 18 months to 35 months). There were 19 cases of bankart lesions, 4 cases of ALPSA lesions and associated with 5 cases of partial tear in the rotator cuff. The anchors employed were knotless anchor (Mitek) for all the cases. Rowe scoring scale was adopted to judge the results after operations. Patients` subjective satisfaction and range of motion of external rotation were addressed together. Results: Rowe scores showed that 20 cases (87%) reaches the level of `good` and hinger. The average patients` satisfaction accounted for 90 points out of 100. It was also found that external rotations averagely decreased by 6.5 degree when the range of motion was in at the side. Conclusion: There were satisfactory results of arthroscopic bankart repair using knotless suture anchors as an operative treatment for traumatic anterior recurrent dislocation on shoulder.
The aim of this study is to evaluate the relationship between traumatic unilateral shoulder instability with Bankart lesion and generalized joint hypermobility. Twenty eight patients and 28 control subjects were included in the study. All of the patients had had their first episode of dislocation during a single definite trauma and had traumatic Bankart lesion which was detected with magnetic resonance imaging. All patients and control subjects were evaluated using Beighton scoring system for generalized joint hypermobility. The mean age of the shoulder instability group and the control group was 26.10 ± 7.60 and 26.64 ± 7.47 years, respectively. Beighton score was found as 3.21 ± 2.11 in the patient group and 2.39 ± 2.06 in the control group. Thirteen cases (46.4%) in the instability group and nine cases (32.1%) in the control group were found to be hypermobile. This difference was not statistically significant. Two patients were reoperated because of recurrence. Both of them had generalized joint hypermobility. Hypermobility may be a predisposing factor to acute traumatic anterior instability and this hypothesis can be investigated in larger series.
The influence of arthroscopy over the last 30 years has induced an evolution towards closer visualisation of the commonly
recognised ligaments (superior, middle and inferior glenohumeral), leading them to be seen as clearly defined bands or folds
rather than as parts of a larger complex; on the other hand, microscopic and histological techniques have resulted in an expansion
of our knowledge of both the inferior glenohumeral ligament and the superior structures, enabling anyone to become aware of
the intimate relationships between coracohumeral and superior glenohumeral ligaments, rotator cuff tendons and the transverse
band.
Instability of the shoulder remains a common problem in active individuals, and expectations for successful outcomes are high. Knowledge gained from the laboratory, from clinical observations, and from improved imaging modalities has allowed a better understanding of the natural history of instability, in turn providing a more rational basis for the development of minimally-invasive techniques for shoulder stabilization. Although open reconstruction is still regarded as the gold standard against which recent innovations must be judged, long-term outcome studies have revealed a significant risk of complications, including stiffness, nerve injury, and degenerative joint disease, in spite of relatively low recurrence rates.
In 2 Swedish hospitals, 88 consecutive shoulders underwent Bankart repair (B), and 97 consecutive shoulders underwent Bristow-Latarjet repair (B-L) for traumatic anterior recurrent instability.
Mean age at surgery was 28 years (B-L group) and 27 years (B group). All shoulders had a follow-up by letter or telephone after a mean of 17 years (range, 13-22 years). The patients answered a questionnaire and completed the Western Ontario Shoulder Index (WOSI), Disability of Arm Shoulder and Hand (DASH), and SSV (Simple Shoulder Value) assessments.
Recurrance resulted revision surgery in 1 shoulder in the B-L group and in 5 shoulders in the B group (P = .08). Redislocation or subluxation after the index operation occurred in 13 of 97 B-L shoulders and in 25 of 87 of B shoulders (after excluding 1 patient with arthroplasty because of arthropathy, P = .017). Of the 96 Bristow shoulders, 94 patients were very satisfied/satisfied compared with 71 of 80 in the B series (P = .01). Mean WOSI score was 88 for B-L shoulders and 79 for B shoulders (P = .002). B-L shoulders also scored better on the DASH (P = .002) and SSV (P = .007). Patients had 11° loss of subjectively measured outward rotation with the arm at the side after B-L repair compared with 19° after Bankart (P = .012). The original Bankart, with tunnels through the glenoid rim, had less redislocation(s) or subluxation(s) than shoulders done with anchors (P = .048).
Results were better after the Bristow-Latarjet repair than after Bankart repairs done with anchors with respect to postoperative stability and subjective evaluation. Shoulders with original Bankart repair also seemed to be more stable than shoulders repaired with anchors.
Bankart repair laxity may contribute to pathologic joint instability. This biomechanical study compared two screw-in suture anchor-suture combinations under tensile loads.
Twelve pairs of scapulae were implanted with either a 3 mm diameter, 14 mm long poly-L/D-lactide suture anchor with a suture eyelet (Group 1) or a 3.1 mm diameter, 11 mm long polylactide suture anchor with a molded eyelet (Group 2). Constructs were cyclically loaded between 25 and 50 N with a 25 N load increase every 25 cycles.
Group 2 displayed greater displacement at failure, had more specimens with > or =2 mm displacement by the 50 N interval (P = 0.014), and had displaced more by 100 N (P < or = 0.046). Group 1 displayed a stronger load-displacement at failure relationship than Group 2 (r (2) = 0.67 vs. r (2) = 0.37).
Construct differences may influence decisions regarding the required number of suture anchor-suture loops, the rehabilitation timetable, and the timing of return to unrestricted activities.
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.
From 1993 through 1996, a multicenter study was conducted on the surgical treatment of patients with posttraumatic recurrent anterior shoulder dislocations. Fifty-six patients (40 men, 16 women; mean age 26 years [range 18-51 years]), were evaluated with shoulder arthroscopy. If a Bankart lesion was present, the patients were randomly allocated to either an arthroscopic reconstruction with the use of biodegradable tacks or an open reconstruction with suture anchors. The postoperative rehabilitation protocol for the two groups was identical. In all patients, the range of shoulder motion, stability, and the Constant and Rowe scores were evaluated at 3, 12, and 24 months postoperatively. Thirty patients were surgically treated with the arthroscopic technique and 26 patients with the open technique. In the arthroscopic group, there were recurrences in 7 (23%) of 30 patients at a mean of 13 months (range 5 to 21 months) after surgery. All patients with stable shoulders had a negative apprehension test result. In the open group, there were recurrences in 3 (12%) of 26 patients at a mean of 10 months (range 2 to 23 months) after surgery (P = not significant). In the arthroscopic group, 2 patients had new traumatic redislocations, whereas 1 patient redislocated during an epileptic seizure. In the open group, 1 traumatic redislocation occurred. The 2-year results in this study demonstrate a large number of redislocations after reconstruction, even in the open surgery group. Patient noncompliance with the rehabilitation protocol and predisposing disease may partially explain these results. A tendency was seen toward more redislocations in the arthroscopic group, which emphasizes the importance of correct patient selection and careful surgical technique in the difficult surgical procedure.
We studied the range of shoulder motion of patients who underwent vertical as compared with horizontal capsulotomies during open Bankart repair for recurrent anterior dislocations of the shoulder. A vertical capsulotomy was used in 10 shoulders and a horizontal capsulotomy was used in 14 shoulders. Except for the method of capsulotomy, the surgical procedure and postoperative rehabilitation were the same. The range of motion was measured at 1.5, 2, 3, 4, 5, 6, 9, and 12 months after the surgery, and at the final follow-up (average, 49 months for the vertical and 26 months for the horizontal group). No dislocations recurred, and the anterior apprehension test was negative in all of the patients in both groups. External rotation in abduction was greater in the horizontal group than in the vertical group; the differences were significantly greater at 9 months and 12 months after surgery and at the final follow-up. External rotation in adduction, flexion, and internal rotation were not significantly different between the groups. We conclude that Bankart repair through a horizontal capsulotomy preserves a better range of external rotation in abduction than does a vertical approach.
Arthroscopic Bankart repair done using suture anchors most closely mimics open repair techniques. The challenge with the arthroscopic technique is tying consistent, good quality arthroscopic knots. A unique knotless suture anchor and method of use for arthroscopic Bankart repair is described. The Knotless Suture Anchor has a short loop of suture secured to the tail end of the anchor. A channel is located at the tip of the anchor that functions to capture the loop of suture after it has been passed through the ligament. The ligament is tensioned as the anchor is inserted into bone to the appropriate depth. Mechanical testing showed increased suture strength in the Knotless Suture Anchor compared with standard suture anchors. This is attributable to the doubled suture configuration that is created with the Knotless Suture Anchor loop. To the author's knowledge, the current study describes the first knotless suture anchor. A secure, low-profile repair can be created without arthroscopic knot tying.
We report the results of the vertical-apical suture Bankart lesion repair in 59 patients with traumatic anteroinferior glenohumeral instability. According to the system of Rowe et al, at a mean follow-up of 42 months (minimum, 2 years), 94.9% (56 patients) had a rating of good or excellent. Three patients had a recurrent dislocation due to further trauma. The mean Rowe score was 94.6, the mean Walch-Duplay score was 94.3, the mean Constant score was 90.4, and the mean rating on a numerical satisfaction scale was 8.7. The mean loss of external rotation with the arm at the side was 2.4 degrees, and in 90 degrees abduction it was 2.2 degrees. Of 44 patients, 35 (79.5%) returned to the same sport at the same level of activity, 7 returned to the same sport at a reduced level of activity, and 2 stopped all sporting activities. There were no complications. We recommend the vertical-apical suture as a technique for Bankart repair that uses absorbable sutures and no suture anchors or tacks.
In the repair of soft tissue to bone using suture anchors, failure of the suture material can occur at the anchor eyelet. This study examines the load strength at which suture material fails with different metallic suture anchor eyelets.
Biomechanical study.
Suture material (Ethibond No. 2, Ethicon, Norderstedt, Germany) was pulled out from 22 metallic suture anchor models at 60 mm/min, and tensile load at failure and failure mode were recorded. Tests were performed either by simultaneous pulling on 2 suture limbs in 3 different directions (straight, at 45 degrees, and at 45 degrees rotated by 90 degrees to the suture anchor axis) or by pulling on 1 suture limb while measuring the resulting force on the second limb. All tests were performed until suture failure. Pulling was performed in single tests on an Instron materials testing machine (High Wycombe, UK), with the anchors held by a vise.
In all cases, the suture failed at the anchor eyelet. Failure load at straight loading ranged from 116 +/- 5 N to 226 +/- 5 N and from 69 +/- 5 N to 193 +/- 7 N when loaded at an angle of 45 degrees. The best results were found with the Statak 5.2-mm (Zimmer, Warsaw, IN): 177 N; Corkscrew 6.5-mm anchor (Arthrex, Naples, FL): 174 N; and PeBA 4.0-mm anchor (OBL Orthopaedic Biosystems, Scottsdale, AZ): 169 N. With each eyelet, sutures failed preferentially in 1 direction, depending on the presence of sharp edges.
Suture material can be cut at suture anchor eyelets. Failure load depends on sharp edges on the eyelet and occurs at forces up to 73% below the breaking strength of the suture material on a smooth hook. Anchors with suture-protecting channels are particularly sensitive to the orientation in which the sutures are loaded.
Repair of soft tissue to bone is increasingly frequently performed using absorbable suture anchors. If a repair fails clinically, it is often impossible to identify the cause of failure at repeat surgery. We report on 2 cases of recurrence of instability after arthroscopic Bankart repair. In reoperation in these cases, all sutures were correctly knotted around the labrum but were intact and torn out of the anchor eyelets. No sign of anchor displacement (3 anchors in each patient) was seen. This is the first clinical report of unambiguous structural suture anchor failure. These observations emphasize the sensitivity of Bankart repair to weak links in the repair chain, which must be avoided.
Clinical experience after failed Knotless suture anchor (Mitek, Westwood, MA) fixations suggested that the Knotless anchor provides considerably less fixation stability than a standard metal anchor. The purpose of this study was to analyze soft tissue fixation to bone comparing a standard and a Knotless metal suture anchor.
In vitro study.
The Mitek GII and Mitek Knotless suture anchors were tested on 7 human cadaveric fresh-frozen glenoids. The anchors were inserted into the glenoid rims, and the sutures of the anchors were fixed to a metal hook attached to the cross-head of a testing machine. Cyclic loading was performed. The gap formation between the metal hook and the glenoid rim, the ultimate failure loads and the modes of failure were determined.
The mean gap formation was significantly greater for the Knotless anchor (3.8 +/- 1.4 mm) than for the GII anchor (2.4 +/- 0.5 mm) after 25 cycles with 50 N repeated load (P =.04). The largest gap of a Knotless fixation was 5.3 mm compared with 3.0 mm for the GII. The ultimate failure load was not significantly different for the Knotless anchor (179 N) and for the GII anchor (129 N). Both anchors failed by either rupture of the suture material or by pullout of the anchors. Conclusions: The GII anchor allows significantly less displacement than the Knotless anchor. Ultimate tensile strength and mode of failure are similar. Greater displacement results in larger gap formation between the soft tissue and the bone. This might weaken and jeopardize the repair.
If reattached soft tissues are subjected to postoperative loading, gap formation may result when using the Knotless anchor. For these conditions, suture fixation with knots may be used instead.
In this prospective study on the Bristow-Latarjet repair, which started in 1980 and ended in 2001, we report the outcome in 118 shoulders where the patients have been followed up for 15 years (mean, 15.2 years; range, 14.3-20.8 years). The study was based on a physical examination, scoring with the system of Rowe et al, and the patients' subjective assessment of the operative result. After 2 years, 1 of 118 shoulders had redislocated and 98% of patients were satisfied with the operative repair. At 15 years' follow-up, 1 patient had undergone revision surgery as a result of recurrence of instability. One patient had had one redislocation during the follow-up period, and one patient reported three recurrences 3 years postoperatively. This patient has had no redislocations during the last 12 years. Furthermore, one more patient had had two recurrences 9 and 12 years after surgery but was very satisfied at follow-up. Subluxations occurred once in 4 patients and several times in 7 patients. These patients were, however, satisfied with the procedures at follow-up. One patient reported posterior subluxations at follow-up. Apprehension was significantly more common in patients with bilateral instability (P =.04) and was found in 19 of 109 shoulders. Of the patients, 90 (76%) were very satisfied with the operative result, 26 were satisfied (22%), and 1 did not know. The patient with revision surgery was considered to be dissatisfied. The incidence of bilateral shoulder instability increased from 22 of 118 (19%) at the time of surgery to 41 of 117 (35%) at 15 years after surgery. We conclude that the overall clinical results, with a satisfaction rate of 98% 15 years after the Bristow-Latarjet repair, were as good as the results reported after any operative method for recurrent anterior shoulder dislocation. However, until the radiologic part of this study is completed, we recommend the procedure only for shoulders with revision because of failed previous surgery and to surgeons familiar with the method.
We prospectively evaluated 61 patients treated arthroscopically for anterior instability of the shoulder at a mean follow-up of 44.5 months (24 to 100) using the Rowe scale. Those with post-operative dislocation or subluxation were considered to be failures. Logistic regression analysis was used to identify patients at increased risk of recurrence in order to develop a suitable selection system.
The mean Rowe score improved from 45 pre-operatively to 86 at follow-up (p < 0.001). At least one episode of post-operative instability occurred in 11 patients (18%), although their stability improved (p = 0.018), and only three required revision. Subjectively, eight patients were dissatisfied. Age younger than 28 years, ligamentous laxity, the presence of a fracture of the glenoid rim involving more than 15% of the articular surface, and post-operative participation in contact or overhead sports were associated with a higher risk of recurrence, and scored 1, 1, 5 and 1 point, respectively. Those patients with a total score of two or more points had a relative risk of recurrence of 43% and should be treated by open surgery.
The use of suture anchors and tacks around the shoulder requires a thorough knowledge of the proper use of the devices and how to insert them. Although typically not technically demanding, suture anchors and tacks can present unique and frustrating challenges to the patient and the surgeon. These challenges can occur whether the procedure is performed via an open or arthroscopic approach, but knowledge of the potential challenges may optimize the surgical result and prevent complications. Complications can be categorized as technique-related or device-related issues (mechanical or biologic failure). Technique-related complications include problems with the delivery systems, anchor malpositioning, and suture management issues, such as knots not sliding. Device-related complications include implant fracture, migration secondary to poor fixation, synovitis from implant degradation, and osteolysis. This review describes the prevention of these and other complications, addresses the indications or need for intervention, and suggests potential solutions when intervention is indicated.
The results of an open Bankart procedure with use of suture anchors were evaluated in 85 shoulders in 83 patients. The mean age was 30 years (range, 16-59 years). The mean number of preoperative dislocations was 18.5. Patients were evaluated prospectively by the Rowe score. Eighty-five shoulders were followed for 1 year and seventy-seven for at least 2 years. The mean follow-up was 3.5 years (range, 1-8.3 years). The Rowe score increased from 30 to 92 points. An excellent or good result was found in 81 of 85 shoulders after 1 year and in 68 of 77 shoulders after 2 years. Seven redislocations occurred, four due to a new trauma. Two patients had recurrent subluxations, one due to a new trauma.
This study compared tap-in Bio-SutureTak suture anchor-#2 FiberWire suture (Group 1) and screw-in Bio Mini-Revo suture anchor-#2 Hi-Fi suture (Group 2) fixation in the glenoid region of interest for Bankart repair, in addition to evaluation of isolated suture loop biomechanical properties under progressive incremental cyclic loads. With knowledge of glenoid apparent bone mineral density (BMD), implant preparation and fit characteristics, and following application of a light manual tensile load, the primary investigator scored each specimen for perceived within group biomechanical test performance using a 0–10 point modified visual analog scale. After scoring, 12 paired constructs were placed in a servo hydraulic device clamp, preloaded to 25 N, and cycled between 25 and 50 Hz with a 25 N load increase every 25 cycles. Group 2 withstood greater load (104.1 ± 56 vs. 70 ± 36.9 N, P = 0.04) and displaced more at failure (13 ± 4.5 vs. 8.6 ± 3.3 mm, P = 0.04). All Group 1 specimens failed prior to reaching 150 N, whereas 25% of Group 2 specimens (n = 3) failed at 200 N. All specimens failed by anchor pullout except for three Group 2 specimens that failed by eyelet breakage at 200 N. Isolated suture testing revealed that Group 1 sutures displaced less at each cyclic load (P = 0.028) and withstood greater failure loads (P = 0.028) than that of Group 2 sutures. Group 2 constructs displayed moderately strong relationships between perceived within group biomechanical test performance and ultimate load (r
2 = 0.55) and displacement at failure (r
2 = 0.67). Group 1 did not display significant relationships. Similar biomechanical performance between 50 and 125 N, greater load at failure, and superior biomechanical test prediction accuracy suggest that the screw-in type Bio Mini-Revo suture anchor-#2 Hi-Fi suture combination may be preferred for Bankart lesion repair in low apparent BMD glenoid processes. The #2 Hi-Fi suture, however, allowed significantly greater displacement than the #2 FiberWire suture at each progressive cyclic load interval.
The purpose of this study was to compare biodegradable glenoid suture anchors by cyclic loading and load to failure testing.
Seven different suture anchors (BioKnotless and Lupine Loop [DePuy-Mitek, Norwood, MA]; BioPushLock, BioSutureTak, and BioFasTak [Arthrex Corp, Naples, FL]; BioAnchor [Conmed Linvatec, Largo FL]; and BioRaptor [Smith & Nephew, Andover, MA]) were tested in 8 matched pairs of human cadaver fresh-frozen glenoids. The anchors were inserted in rotation into different glenoid rim positions. Sutures attached to the anchors were fixed to an Instron 8871 machine (Instron, Canton, MA) and cyclic loading and destructive testing were performed. The cyclic displacement at 100 and 500 cycles, stiffness, ultimate failure strength, and mode of failure were determined.
No statistical difference was found in the ultimate failure load for any of these anchors. The Lupine Loop and BioAnchor had greater 100 cycle and 500 cycle mean displacements than the BioPushLock and BioSutureTak. The Lupine Loop also had greater 100 cycle and 500 cycle mean displacement than the BioFasTak (P < .05). The BioAnchor had greater mean 500 cyclic displacement than the BioFasTak (P < .05). Mean BioSutureTak stiffness was greater than the Lupine Loop, BioAnchor, BioKnotless, and BioRaptor (P < .05).
No differences in ultimate failure strength after cyclic loading were found in these seven biodegradable glenoid anchors (BioKnotless, Lupine Loop, BioPushLock, BioSutureTak, BioFasTak, BioAnchor, and BioRaptor). Most displacement occurred in the first 100 cycles. Displacement at 500 cycles was greater for the Lupine Loop and the BioAnchor than the BioPushLock, BioSutureTak, and BioFasTak. Failure was principally by the anchor pulling out of bone except for the BioSutureTak, which also failed by the suture loop eyelet pulling out of the anchor body, and the BioPushLock which failed by the suture slipping past anchor.
Biodegradable glenoid anchors did not show statistical difference in ultimate failure load after cyclic loading.
An anterior glenoid labrum reconstruction in conjunction with a modified anterior-inferior capsular shift is described and was performed in 64 patients (69 shoulders) with traumatic anterior or anterior-inferior glenohumeral instability. Sixty-three operations were performed for recurrent dislocation and six for recurrent subluxation. The patients in this study were extremely active in sports, with the majority of Tegner ratings exceeding 7.0. Fifty-six patients with 61 operated shoulders were available for clinical follow-up at an average of 36 months (range 28 to 78 months). With rating scales from the American Shoulder and Elbow Surgeons, pain improved from an average of 3.1 to an average of 4.4, stability improved from 1.1 to 4.5, and function improved from 2.5 to 3.8. Postoperative average ranges of motion were 180° of forward elevation, 72° of external rotation with the arm at the side, 92° of external rotation with the arm at 90° of abduction, and 90° of internal rotation with the arm at 90° of abduction. Ninety-five percent of the patients were satisfied with the procedure. Five patients suffered a recurrent dislocation, four from significant trauma. One additional patient experienced an episode of subluxation early in the recovery period. According to the criteria of Rowe, 90% had excellent or good results.
The most common type of shoulder instability is posttraumatic anterior instability. Treatment is surgical. Of the several procedures used, the standard one is Bankart repair. However, this procedure is technically demanding. To simplify it a suture anchor such as Mitek anchors may be used. A prospective randomized study was conducted to compare Mitek anchors with bone sutures. The results showed that Mitek anchors shorten surgical time by making reattachment of the capsule easier. Shoulder muscle strength, range of motion, and frequency of recurrence were equally good in the anchor group and bone suture group. A roentgenographic method allowed exact measurement of placement of the anchors. This method showed at 2-year follow-up evaluation that the anchors were still in the anterior glenoid. No metal-related complications are found at the 2-year follow-up evaluation.
A postoperative follow-up of one and one-half to ten years was obtained in 114 of 121 patients who underwent either a Bankart or a modified Putti-Platt procedure. In the forty-six patients who had a Bankart operation, there was one recurrence (2 per cent) compared with thirteen recurrences (19 per cent) in the sixty-eight patients who had a modified Putti-Platt procedure. Twelve (36 per cent) of the latter recurrences occurred in patients who were twenty-five years old or younger at the time of the operation and only one occurred in the patients who were more than twenty-five years old. The restriction of outward rotation after shortening of the subscapular tendon averaged 6 degrees as compared with 16 degrees after a Bankart operation. A modified Putti-Platt procedure (shortening of the subscapular tendon) is recommended only for patients who are more than thirty years old. It does offer certain advantages for them because of the simplicity of the procedure and the short duration of the operation.
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.
We assessed the effectiveness of a new suture anchor that has been designed to anchor sutures into a blind, straight hole drilled in bone. The strength of fixation in glenoid bone is 67 N for the No. 0 anchor and suture, and 82 N for the No. 2 device with suture. During 1988 and 1989, 32 patients underwent a modified Bankart reconstruction for recurrent anterior glenohumeral instability at two centers as part of a prospective study of this modified technique. There were no complications as a result of the technique. The four surgeons involved agreed that the suture anchor simplified the procedure. Seventeen patients have been reviewed, with more than 1 year followup. Ninety-four percent had good to excellent results according to the Bankart rating scale. There was one recurrent dislocation in a football player.
Transient subluxation of the shoulder may cause the so-called dead-arm syndrome, which is characterized by a sudden sharp or 'paralyzing' pain when the shoulder is moved forcibly into a position of maximum external rotation in elevation or is subjected to a direct blow. This syndrome also may occur during throwing, repetitive forceful serving in tennis, or working with the arm in a strained position above shoulder level. Sixty shoulders with the dead-arm syndrome, apparently caused by transient subluxation of the shoulder, were treated and analyzed after follow-up periods ranging from two to sixteen years. Two groups of patients with this syndrome were identified. The patients in Group I had the sensation that subluxation was occurring when they used the arm in elevation; in Group II, the patients were not aware of slipping out or instability of the shoulder. Both groups had similar mechanisms of injury, similar symptoms and physical findings, comparable pathological lesions at operation, and similar results after the same surgical treatment. A Bankart procedure was performed in thirty-two shoulders in which a Bankart lesion was found, and a modified Bankart repair (capsulorrhaphy) was done in the remaining eighteen in which the labrum was intact. The results in the fifty shoulders treated surgically were 70 per cent excellent, 24 per cent good, and 6 per cent fair. Ten shoulders were treated by non-surgical means. In twenty (54 per cent) of the thirty-seven shoulders in which the superior aspect of the musculotendinous cuff was examined, a large opening in the capsule was noted in the interval between the supraspinatus and subscapularis tendons below the superior glenohumeral ligament. This opening may be a factor in anterior instability of the shoulder.
Suture anchors of various designs are gaining acceptance for open and arthroscopic procedures. The rapid proliferation of these devices challenges those using them to apply objective criteria for device selection. Comparative data on implant security in different settings, modes of failure, and ultimate failure strengths is lacking. This study was undertaken to independently develop such data for an objective comparison of the suture anchors currently available. Using a fresh never-frozen porcine femur model, 10 samples of each of the 14 different anchors tested were inserted into each of the three different test areas; diaphyseal cortex (usually 3- to 4-mm thick), metaphyseal cortex (usually 1- to 2-mm thick), and a cancellous bone "trough". The suture anchors were threaded with 0.018-inch stainless steel wire or, for anchors requiring a more flexible suture, 0.018-inch stainless steel 1 x 7 wire braid. Tensile stress parallel to the axis of insertion was applied at a rate of 12.5 mm/second by an Instron 1321 (Instron Corp, City, State) until failure. Average failure strength was calculated for each anchor at each test area. The anchors tested were the Mitek G2, Mitek G3, Mitek G4 (Mitek Surgical Products, Norwood, MA), Linvatec Revo screw (Linvatec, Largo, FL), Acufex TAG Wedge, Acufex TAG Rod 2 (Acufex Microsurgical, Mansfield, MA), Statak models 1.5, 2.5, 3.5, 5.0, and 5.2 (Zimmer, Warsaw, IN), Arthrex ESP (Arthrex Inc., Naples, FL), Arthrotek Harpoon, and Arthrotek LactoSorb (Arthrotek, Warsaw, IN). The average failure strength of each of these anchors in the diaphyseal cortex, metaphyseal cortex, and cancellous bone is reported.(ABSTRACT TRUNCATED AT 250 WORDS)
We previously reported early results of a new technique using a suture anchor to perform a modified Bankart reconstruction. That study included patients from two medical centers and had an average followup of only 1 year. This report includes patients from a single center with followup extended to a mean of 42 months (range, 33 to 61). Between April 1988 and August 1991, 53 patients with recurrent anterior glenohumeral instability underwent modified Bankart reconstruction with the use of a suture anchor. Thirty-two patients met inclusion cri teria (identifiable Bankart lesion, open repair with suture anchors, and minimum followup of 2 years); 4 patients were lost to followup. There have been no complications as a result of this technique. Ninety-three percent of the patients in the study had objectively excellent or good results. There were 2 failures with recurrent anterior dislocation.
The use of a suture anchor can simplify the Bankart reconstruction. At average followup of 3 years, 26 pa tients have returned to presurgery activity levels without recurrent dislocation or subluxation. However, careful attention to anchor placement at the junction of articular cartilage and the glenoid neck is necessary to avoid technical failure.
We evaluated three mechanical soft tissue fixation devices (SuperAnchor, Suretac, and the Instrument Makar [IM] Bioabsorbable Staple) in a cadaveric model by examining ultimate tensile failure and modes of failure in simulated Bankart repairs. We attempted to realistically evaluate the strengths of soft tissue reattachment procedures at the anterior glenoid under worst-case conditions--load to failure. Twenty fresh-frozen cadaveric shoulders were used in this investigation. Each of the three techniques was performed in each anterior glenoid rim at one of three locations: superior, middle, or inferior. The subscapularis muscle-tendon was harvested, used in the repair, and loaded to failure. The mean load at failure for the SuperAnchor was 217.32 N; for the IM Staple, 132.32 N; and for the Suretac, 122.37 N. A two-sample t-test demonstrated that the load at failure for the SuperAnchor was statistically greater (P < 0.001) when compared with the IM Staple and Suretac. There was no statistical difference between load at failure for the Suretac and the IM Staple. The most common failure mode for the Mitek was suture breakage (71%). Anchor pullout from bone was the most common failure mode for the IM Staple (75%) and Suretac (94%).
Suture anchors are increasingly used to secure tendons or ligaments to bone. These devices are applicable for arthroscopic shoulder stabilization and rotator cuff repair. This study reports the in vivo characteristics of four anchors, including one absorbable anchor composed of poly-L-lactic acid. Failure strength and method of failure were recorded for these anchors as a function of time. Samples of four anchors [Mitek G2, Zimmer Statak, Acufex TAG wedge, and the absorbable Arthrex expanding suture plug (ESP)] were implanted into ram femurs and harvested at intervals. Each bone-anchor-suture system was stressed to failure. The failure force and failure method was recorded. Mitek G2 and Statak suture anchors failed consistently at 30 pounds by suture breakage. They had no implantation difficulties. The TAG wedge exhibited suture pull-out and implant flipping at insertion. The TAG wedge failed by suture cut-out, anchor pull-out, and suture breakage. Its average failure strength was initially 16 pounds, but increased to 28 pounds at 2 weeks and reached the 30-pound level by 4 weeks. The ESP poly-L-lactic acid anchors experienced implantation breakage in 20% because of their greater length and composition. At pull-out testing, the ESP failed by suture cut-out, anchor pull-out, and suture breakage. Failure strength was initially 27 pounds, was 17 pounds at 2 weeks, and increased to 30 pounds by 6 weeks. The absorbable ESP does not have initial pull-out strength comparable with the Mitek and Statak suture anchors but does achieve this strength by 6 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)
Five commercially available suture anchor devices were tested to failure in human cadaveric proximal tibiae. A total of 198 trials were completed. Insertion was uncomplicated for all anchors, with the exception of the Acufex Rod TAG device, with five of 22 (23%) of these breaking upon insertion into thicker cortical bone. Overall, the anchors performed significantly (p < 0.05) better when placed in thicker cortical bone, further away from the joint surface, and when loaded in a direction parallel to the bone surface. The Mitek GII anchor failed (pulled out of bone) less often than the other anchors (19% vs. 46%). In loading perpendicular to the bone surface, the Mitek GII and Statak were the strongest (p < 0.05), with mean loads at failure of 82.5 and 90.2 N, respectively. The Acufex Rod TAG, Acufex Wedge TAG, and Mitek GI failed at 67.2, 65.5, and 49.4 N respectively.
The rapid proliferation of suture anchors continues. Our prior report on the pullout strength of 14 different anchors is supplemented by a similar test conducted on 8 additional anchors. Comparative data on modes of failure and failure strengths (ultimate loads to failure) for these new devices are compared statistically with the previously tested anchors. In a fresh never-frozen porcine femur model, 10 samples of each of the additional anchors tested were threaded with stainless steel sutures and inserted into three different test areas (diaphyseal cortex, metaphyseal cortex, and a cancellous trough). Tensile stress parallel to the axis of insertion was applied at a rate of 12.5 mm/s by an Instron 1321 testing machine (Instron Corp, Canton, MA) until failure and mean anchor failure strengths calculated. The anchors tested were the Mitek G2 as a control, miniMitek, Mitek Superanchor, Mitek Rotator Cuff anchor (Mitek Products, Westwood, MA), Innovasive Devices Radial Osteal Compression device (Innovasive Devices, Hopkinton, MA), Arthrex Fastak (Arthrex Inc, Naples, FL), Arthrotek miniHarpoon (Arthrotek, Warsaw, IN), Orthopedic Biosystems PeBA 3 and PeBA 5 (Orthopedic Biosystems, Scottsdale, AZ), and AME 5.5 screw (American Medical Electronics, Richardson, TX). Failure mode (anchor pullout, suture eyelet cut out, or wire breakage) was generally consistent for each anchor type. The size of insertion hole is clinically important and each anchor's performance was evaluated as a function of its minor diameter or drill hole. For screw anchors, the larger the minor diameter of the screw, the higher the mean failure strengths in all three test areas (P = .001). However, larger drill holes for non-screw anchors resulted in lower mean failure strengths in cancellous bone (P = .03) and diaphyseal cortex (P < .005).
Suture anchors have simplified anterior capsule labral reconstruction. During rehabilitation the shoulder goes through many repetitions of range of motion exercises. These exercises will repetitively submaximally load the anchor and in theory should reduce the pullout strength of the suture anchor. No published reports exist on the fatigue strengths and properties of one of the most commonly used anchors: Mitek GII suture anchors. Fifty trials of cyclic submaximal load were done on 22 cadaveric glenoids with an average age of 66.8 years (range, 40 to 90 years). At two to three different sites on the same specimen, the anchors were inserted according to manufacturer's specifications. The anchors were tested to failure on a Instron 1331 servohydraulic mechanical testing system at 2 Hertz sinusoidal loading pattern using steel sutures and a predetermined load. There were 22 (44%) tests performed in the superior quadrant and 28 (56%) tests in the inferior quadrant. All anchors pulled out, and no wires broke. There were statistically significant differences between the superior and inferior portion of the glenoid with regard to number of cycles to failure at a given maximum load. The anchors underwent an average of 6,220 cycles before pullout at an average load of 162 N (SD = 73 N). In the superior quadrant, the average ultimate pullout strength was 237 N (SD = 42 N), whereas in the inferior quadrant the average ultimate pullout strength was 126 N (SD = 36 N). Hence, the ultimate pullout strength of the Mitek GII anchor was significantly higher (P < .002) in the superior quadrant than in the inferior quadrant. Using a least squares regression analysis, it was possible to predict the fatigue life of the superiorly and inferiorly placed suture anchors over a wide range of cycles. The R-squared values for trendlines showed good reliability (superior R2 = 0.55; inferior R2 = 0.28). The fatigue life curves for the two different quadrants were normalized using the ultimate pullout strength. This new, universal curve predicts the fatigue life of the Mitek GII anchor as a percentage of the ultimate pullout strength for any selected location. For a clinically relevant number of cycles, no more than approximately 40% to 50% of the ultimate pullout strength of the suture anchor can be cyclically applied to the anchor to guarantee a life for the duration of rehabilitation. For the entire system, the inferiorly placed anchors dictate the amount of cyclically applied load the system can experience without failing, and rehabilitation should be adjusted accordingly.
1. General joint laxity affecting more than three joints was found in 7 per cent of normal schoolchildren. Similar laxity was found in fourteen of a random series of forty-eight girls, and in nineteen of twenty-six boys, with non-familial congenital dislocation of the hip. Such laxity was also found in four of seven girls and five of seven boys with familial (first degree relative affected) congenital dislocation of the hip.
2. It is concluded that persistent generalised joint laxity, which is often familial, is an important predisposing factor to congenital dislocation of the hip in boys. It is less important in girls, except perhaps in familial cases, as in girls there is an alternative temporary hormonal cause of joint laxity.
Pathomechanics of the loose shoulder [in Japanese]
- Endo
Anterior and antero-inferior shoulder instability: treatment by glenoid labrum reconstruction and a modified capsular shift procedure.
- Paulos LE
- Evans IK
- Pinkowki JL
Investigational plan and results. (Clinical data for internal information of the Zimmer Division
- J T Malouf
- E M Goble
- A M Banks
- J Horstman
- A Newman