Arthroscopic Stabilization for Recurrent Shoulder Instability With Moderate Glenoid Bone Defect in Patients With Moderate to Low Functional Demand

doi:10.1016/j.arthro.2014.03.023

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 30, Issue 8, August 2014, Pages 921-927

https://doi.org/10.1016/j.arthro.2014.03.023 Get rights and content

Purpose

The purpose of this study was to investigate the functional outcomes of arthroscopic Bankart repair for recurrent shoulder instability in the setting of moderate glenoid bone defect ranging from 20% to 30% in patients with moderate to low functional demand.

Methods

This study included 36 patients with unilateral recurrent instability and glenoid bone defects of 20% to 30% treated with arthroscopic stabilization. Glenoid bone loss was estimated on the en-face view of preoperative 3-dimensional computed tomography. Joint laxity was assessed clinically by use of the Beighton and Horan criteria, and patients were divided into 2 groups based on the presence of excessive joint laxity, group L (n = 13), or absence of excessive joint laxity, group N (n = 23). Functional assessments were performed with the patient-reported activity level; subjective shoulder value; Rowe score; and University of California, Los Angeles shoulder score.

Results

The mean glenoid defect size was 25.1% (range, 20% to 29%), and the overall functional outcomes improved significantly after surgery. A return to greater than 90% of the premorbid activity level was reported by 72% of patients (26 of 36 patients), and patient satisfaction was 83% (30 of 36 patients). There was no significant difference in functional outcomes between groups L and N (subjective shoulder value, 85.0% for group L v 88.9% for group N, P = .397; Rowe score, 83.5 for group L v 92.8 for group N, P = .537; and University of California, Los Angeles shoulder score, 32.2 for group L v 31.9 for group N, P = .697). Recurrent instability occurred in 4 patients (11%), 3 patients in group L (3 of 13, 23%) and 1 patient in group N (1 of 23, 4%), but this difference was not statistically significant (P = .125).

Conclusions

Arthroscopic stabilization for recurrent shoulder instability in patients with moderate to low functional demand produced satisfactory outcomes despite the presence of moderate glenoid bone defects of 20% to 30%. For patients with excessive joint laxity, however, arthroscopic stabilization may not be reliable, with a recurrence rate of 23%.

Level of Evidence

Level IV, therapeutic case series.

Section snippets

Study Population

From March 2005 to May 2011, 179 patients underwent arthroscopic Bankart repair with suture anchors for chronic anterior shoulder instability. The indications for arthroscopic Bankart repair in this patient group were (1) recurrent shoulder dislocation refractory to conservative treatment for at least 3 months; (2) positive apprehension sign with the shoulder positioned in 90° of abduction and external rotation; (3) glenoid bone deficiency of less than 30% when measured on the en-face view of

Patient Demographic Data

This study included 30 male and 6 female patients, and their mean age was 26.1 ± 8.9 years (range, 18 to 55 years). The dominant extremity was affected in 28 patients. Excessive joint laxity was noted in 13 patients (group L), and normal joint laxity was found in 23 patients (group N). The mean duration of symptoms from the time of initial injury until the time of surgical intervention was 23.1 ± 8.8 months (range, 10 to 48 months), and the mean duration of follow-up after surgery was 41.7 ±

Discussion

The principal findings of this study were that we noted satisfactory outcomes after arthroscopic stabilization for recurrent shoulder instability in patients with moderate to low functional demand despite moderate glenoid bone defects. The overall failure rate was 11% (4 of 36 patients): 3 patients in group L (3 of 13, 23%) and 1 in group N (1 of 23, 4%). Nevertheless, there was no significant difference between the 2 groups. Among the 36 patients, a bony Bankart lesion was identified in 13

Conclusions

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Cited by (27)

Arthroscopic Dynamic Anterior Stabilization Using Either Long Head of the Biceps or Conjoined Tendon Transfer for Anterior Shoulder Instability Results in a Similarly Low Recurrence Rate
2023, Arthroscopy - Journal of Arthroscopic and Related Surgery
To compare the clinical outcomes of arthroscopic dynamic anterior stabilization (DAS) between transferring the long head of the biceps (DAS-LHB) and the conjoined tendon (DAS-CT) for anterior shoulder instability with <15% glenoid bone loss.
From January 2016 to May 2019, a total of 63 patients who underwent DAS for recurrent anterior shoulder dislocation with <15% glenoid bone loss were included, comprising 33 patients in DAS-LHB group and 30 patients in DAS-CT group. Clinical outcomes were assessed preoperatively and at a minimum 3-year follow-up, including patient-reported outcomes, range of motion, and return to sports (RTS). Postoperative recurrent instability (including dislocation, subluxation, and subjective instability with a positive apprehension test), revisions and complications also were recorded.
No significant demographic characteristics difference was detected between the DAS-LHB (26.3 ± 7.9 years) and DAS-CT groups (26.0 ± 6.7 years). At the latest follow-up, there were no significant differences between the 2 groups in functional scores: Oxford Shoulder Instability Score (14.8 ± 2.8 vs 15.2 ± 3.6), Rowe score (95.9 ± 6.5 vs 93.2 ± 10.2), visual analog scale for pain (0.8 ± 1.2 vs 0.7 ± 1.7), and American Shoulder and Elbow Surgeons (95 ± 8.8 vs 95.2 ± 9.1) (all P > .218). No significant difference was detected between groups in the rates of RTS (90.1% vs 86.7%, P = .700) and RTS at previous level (78.7% vs 73.3%, P = .258), respectively. No recurrent dislocation occurred in either group. One patient felt occasional subluxation in the DAS-LHB group, and one was positive for the apprehension test in each group. One patient presented with postoperative shoulder stiffness and underwent a secondary arthroscopic debridement in the DAS-CT group.
Comparable rates of recurrence, complication, return to sports, and subjective shoulder function were observed between DAS-LHB and DAS-CT groups.
Level III, retrospective comparative therapeutic trial.
Treatment of recurrent anterior inferior instability associated with glenoid bone loss: Iliac crest
2022, Surgical Techniques of the Shoulder, Elbow, and Knee in Sports Medicine, Third Edition
Management of recurrent shoulder instability associated with glenoid bone loss can be challenging. Soft tissue stabilization procedures alone are associated with high rates of recurrent instability in patients with significant glenoid bone deficiency. Bone graft stabilization procedures such as the J-bone graft procedure are indicated in patients suffering from anterior shoulder instability and critical glenoid bone loss. The J-bone graft procedure constitutes harvesting an autologous iliac crest bone graft that is shaped to resemble the letter “J” and is press-fit impacted into a scapula neck osteotomy, thus allowing for implant-free anatomic glenoid reconstruction. Long-term follow-up shows the J-bone graft procedure demonstrates sustained glenohumeral stability and shoulder function over time with excellent results regarding range of motion and strength. This chapter discusses the preoperative considerations, surgical technique, and aftercare of the J bone procedure for treatment of recurrent anterior shoulder instability with critical glenoid bone loss.
Bankart Repair With Subscapularis Augmentation in Athletes With Shoulder Hyperlaxity
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
The purpose of this study was to demonstrate that arthroscopic Bankart repair with associated arthroscopic subscapularis augmentation (ASA) could be a valid surgical option in the treatment of anterior shoulder instability, in collision and contact sports athletes, affected by shoulder hyperlaxity.
In total, 591 arthroscopic Bankart repairs plus ASA were performed in 6 shoulder centers from 2009 to 2017. Inclusion criteria were the following: collision and contact sports activities, recurrent anterior instability associated with hyperlaxity and glenoid bone loss (GBL) < 15%. Exclusion criteria were GBL > 15%, voluntary instability, multidirectional instability, pre-existing osteoarthritis and throwing athletes. The minimum follow-up was 24 months. Hyperlaxity was clinically evaluated according to Neer and Coudane-Walch tests. Before surgery, all patients underwent magnetic resonance imaging and computed tomography scanning. Pico area method was used to assess the percentage of GBL. Patients were operated on by 6 surgeons, and their functional outcomes were evaluated by 2 independent observers. The Western Ontario Shoulder Instability Index (WOSI), Rowe, American Shoulder and Elbow Surgeons (ASES) scores were used to assess results.
Overall, 397 patients with evidence of shoulder hyperlaxity (positive sulcus sign in ER1 position and Coudane-Walch test > 85°) met all inclusion criteria. The mean WOSI score was 321; the mean Rowe score rose from 68.5 to 92.5 (P = .037), and the ASES score rose from 71.5 to 97.4 (P = .041). Seven patients (1.6%) had atraumatic redislocation, and 9 patients (2.2%) had post-traumatic redislocation. At final follow-up the mean functional deficit of external rotation was 15° with the arm in adduction (ER1 position) and 10° in abduction (ER2 position).
The Bankart repair plus ASA has been demonstrated to be safe and effective for restoring joint stability in patients practicing collision and contact sports or affected by chronic anterior shoulder instability associated with GBL (<15%) and hyperlaxity, without compromising external rotation.
Level IV, case series.
High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review
2021, Arthroscopy, Sports Medicine, and Rehabilitation
Citation Excerpt :
The 2 observers agreed on 83.7% of the articles with a Cohen’s kappa of 0.67. On the Coleman methodology score, one scored poor,11 43 studies scored fair,12-56 37 scored good,57-91 and 8 scored excellent92-99 (Table 1). From the included studies only 30 studies (34%) reported on the definition of a subluxation, and 26 studies (29%) reported on the definition of a dislocation.
To determine the definitions for recurrence used in the literature, assess the consensus in using these definitions, and determine the impact of these definitions on recurrence rates.
A literature search was performed in PubMed and EMBASE including studies from 2000 to 2020 reporting on recurrence rates after anterior arthroscopic shoulder instability surgery. Dislocation, apprehension, subluxation and recurrence rates were compared.
Ninety-one studies were included. In 68% of the eligible studies, recurrence rates are not well defined. Thirty (33%) studies did not report on dislocations, 45 (49%) did not report on subluxations, and 58 (64%) did not report on apprehension. Seventeen different definitions for recurrence of instability, 4 definitions of dislocations, and 8 definitions of subluxation were used.
Recurrence rates are poorly specified and likely underreported in the literature, hampering comparison with results of other studies. This highlights the need for a consensus on definition of recurrence across shoulder instability studies. We recommend not using the definition recurrence of instability anymore. We endorse defining dislocations as a radiographically confirmed dislocation or a dislocation that is manually reduced, subluxations as the feeling of a dislocation that can be (spontaneously) reduced without the need for a radiographically confirmed dislocation, and a positive apprehension sign as fear of imminent dislocation when placing the arm in abduction and external rotation during physical examination. Reporting on the events resulting in a dislocation or subluxation aids in making an estimation of the severity of instability.
Level IV, systematic review.
Does an “Off-Track” Hill-Sachs Lesion That Is Misclassified as “Non-Engaging” Affect Outcomes From Bankart Repair Alone Compared With Bankart Repair Combined With Remplissage?
2021, Arthroscopy - Journal of Arthroscopic and Related Surgery
To determine how intraoperative assessment (engagement test) may affect recurrent dislocation rate and to compare the clinical outcomes, recurrence rates, and presence of on-/off-track conditions between cases that received arthroscopic Bankart repair alone (nonengaged Hill-Sachs lesion) and Bankart repair with remplissage (engaged Hill-Sachs lesion).
We retrospectively reviewed 213 patients who underwent arthroscopic Bankart repair alone (186 patients with nonengaging lesions, group A) or with remplissage (27 patients with engaging lesion, group B) for recurrent anterior shoulder instability with <25% glenoid bone defect. The presence of an engaging Hill-Sachs lesion was determined during arthroscopic evaluation. On-track or off-track lesions were assessed retrospectively from preoperative 3-dimensional (3D) computed tomography (CT).
Mean glenoid bone defect was 13.7% in group A and 20.7% in group B (P < .001). Off-track lesions were identified in 8.1% (15/186) and 100% (27/27) in group B. At the final follow-up (minimum 2 years; mean follow-up periods after surgery of 50.1 months in group A and 47.7 months in group B), there were no significant differences in shoulder functional scores and recurrence rates between groups, despite improvement after surgery. In the off-track lesion (group A-1: nonengaging but off-track lesion), recurrence instability occurred in 9 patients (60%, 9/15). Also, comparing group A-1 and group B, we noted significant differences in shoulder functional scores and recurrence rates (P < .001).
Of 186 patients, 8.1% with nonengaging Hill-Sachs lesions during direct arthroscopic examination under anesthesia actually demonstrated off-track lesions on preoperative 3D CT scans retrospectively, with 60% experiencing recurrent instability. Intraoperative manual assessment for Hill-Sachs engagement was inferior to 3D CT scan in establishing the presence of off-track defects.
III, retrospective comparative study
Does creating a trough on the anterior glenoid rim make a difference in Arthroscopic Bankart repair using suture anchors? A mid-term follow-up retrospective study
2019, Journal of Orthopaedic Science
Citation Excerpt :
Wolf [1] introduced arthroscopic anterior shoulder stabilization using suture anchors in 1989 and reported good results. This procedure has been reported to have an instability recurrence rate comparable to of those other arthroscopic repair procedures, ranging from 5.9% to 35.0% [9,10,13,30–37]. A prospective, level 1 study involving 302 patients [40] reported a recurrence rate of 13.2%.
Creating a trough on the anterior glenoid rim is one of the methods used for arthroscopic Bankart repair with suture anchors. The purpose of this study was to analyze clinical and radiological outcomes of arthroscopic Bankart repair with suture anchors; to compare between the outcomes of surgical procedures with and without trough.
Clinical and radiological outcomes were evaluated for 116 patients who underwent arthroscopic Bankart repair at our institute from 2005 to 2011. The mean follow-up was 5.2 years (range, 2–8.8 years). All data were divided into trough group (n = 62) and non-trough group (n = 71). Clinical and functional outcomes were assessed pre- and postoperatively as range of motion (ROM), pain on the visual analog scale (p-VAS), function on the visual analog scale (f-VAS), and Rowe score. Radiological outcomes were also evaluated.
The overall postoperative clinical and functional outcomes improved significantly (P < .001). A total of 8 patients (6.8%) showed recurrent instability. Radiologic findings showed mild arthritis in 27 cases (23.1%), moderate arthritis in 6 cases (5.1%), and no severe arthritis. 32 patients showed anterior apprehension after surgery, and 22 out of those 32 patients were from non-trough group. However, no significant difference between the trough and non-trough groups was found with respect to clinical and functional outcomes (P > .05).
The additional procedure of creating a trough did not improve clinical outcomes in terms of frank dislocation; however, at the final follow-up, patients with the trough showed less anterior apprehension. Overall, arthroscopic Bankart repair using suture anchors had relatively good clinical outcome, with a redislocation rate of 6.8%.
Level III, Case series.

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: The authors report that they have no conflicts of interest in the authorship and publication of this article.

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Original ArticleArthroscopic Stabilization for Recurrent Shoulder Instability With Moderate Glenoid Bone Defect in Patients With Moderate to Low Functional Demand

Purpose

Methods

Results

Conclusions

Level of Evidence

Section snippets

Study Population

Patient Demographic Data

Discussion

Conclusions

Arthroscopy

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Arthroscopy

Arthroscopy

The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: A cadaveric study

J Bone Joint Surg Am

Recurrent shoulder instability: Current concepts for evaluation and management of glenoid bone loss

J Bone Joint Surg Am

Glenoid bone deficiency in recurrent anterior shoulder instability: Diagnosis and management

J Am Acad Orthop Surg

Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft

Am J Sports Med

The Latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair: A retrospective case series of forty-nine consecutive patients

J Bone Joint Surg Am

Treatment of recurrent dislocation of the shoulder

Lyon Chir

Original Article
Arthroscopic Stabilization for Recurrent Shoulder Instability With Moderate Glenoid Bone Defect in Patients With Moderate to Low Functional Demand