Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Brett D. Owens, MD*†,
Keller Army Hospital, West Point, NY
Posted November 2009
While the technical improvements in arthroscopic Bankart repair have allowed
the outcomes to approach those of the classic open repair method1,
recurrent instability remains a concern. The ability to identify risk factors
for failure with arthroscopic Bankart repair may allow surgeons to augment their
arthroscopic capsulolabral repair or opt for open stabilization in high-risk
patients. To date, investigators have recognized the following factors as having
negative prognostic value in patients undergoing primary arthroscopic Bankart
repair: poor soft-tissue quality2, sulcus sign and/or inferior laxity2,3,
bilaterality2, participation in collision sports2,4, glenoid
bone loss3,5,6, bone loss in the humeral head3,6, and repairs
consisting of three or fewer anchors3.
Porcellini et al. report on a large series of arthroscopic Bankart repairs
in a selected population and hypothesize that risk factors for recurrence can
be determined on the basis of preoperative data. During a three-year period,
647 shoulders underwent surgical stabilization for instability by a single surgeon.
Of these, 422 (65%) met the strict inclusion criteria for this study and 385
(91%) were successfully followed for three years. The authors excluded patients
with atraumatic mechanisms, voluntary instability, ligamentous laxity, sulcus
sign, prior surgery, osseous Bankart lesions, glenoid bone loss, and those not
treated surgically within twelve months of dislocation, those with seven or more
dislocations, and those whose repair required fewer or more than three suture
anchors. The authors do not provide the specific reasons for their exclusion
of 203 patients in this study. The authors also make no mention of Hill-Sachs
lesions in their inclusion criteria. There was no quantification made of the
cohort's activity level, although the authors do state that none of the patients
were professional athletes.
After the performance of an arthroscopic Bankart repair with suture anchors,
patients were followed for three years and failure was defined as either a recurrent
subluxation or dislocation. However, the authors do not clarify this distinction
in their results and do not mention subluxation again in the manuscript. In thirty-one
(8.1%) of the 385 patients, the procedure was classified as a failure due to
recurrence. The authors analyzed these failures and found that the following
factors were statistically significant: age of twenty-two years or less, male
sex, and a time to surgery of greater than six months.
While these results are not surprising, they do warrant some scrutiny. The
first two factors identified (age of twenty-two years or less and male sex) are
two known risk factors for initial glenohumeral instability7 as well
as recurrence following nonoperative treatment8. These variables may
serve as proxy measures for activity, with the possibility that a higher proportion
of these patients may return to contact athletics. That a greater than six-month
delay in stabilization was associated with a higher failure rate may be explained
by the incremental pathologic changes noted with repetitive instability events9.
The differentiation between a medialized anterior labroligamentous periosteal
sleeve avulsion (ALPSA) lesion and a classic Bankart avulsion has been previously
investigated. Ozbaydar et al. showed that patients with ALPSA lesions had a history
of sustaining more instability events prior to stabilization and had a higher
failure rate with stabilization as compared with those with Bankart lesions10.
Porcellini et al. failed to show a significant difference in failure rates when
comparing the type of lesion and the number of instability events in this study,
and the authors suggest that the study may be underpowered to show this effect.
The major methodological concern with this study is the authors' decision
to dichotomize their patient variables for analysis. The authors do not provide
reasoning for their selection of twenty-two years of age at time of dislocation,
six months until stabilization, or three dislocation events as cut-off points
in their dichotomization. Nor do the authors provide an explanation for their
decision to exclude patients with seven or more dislocation events or who underwent
stabilization more than one year after the injury.
Despite these methodological concerns, there are some important take-home
points from this study. The authors report an acceptable rate of recurrence (8.1%)
in a large (385 shoulders) series of arthroscopic Bankart repairs. Porcellini
et al. were able to show a higher rate of failure in patients who were twenty-two
years of age or younger and male, which may be explained by greater activity
level in that population. This supports the aggressive surgical treatment of
these high-risk patients. They also found a higher failure rate in patients who
undergo stabilization later than six months after their initial event, lending
further credence to the concept of early stabilization in high-risk patients
who have sustained a first-time glenohumeral dislocation.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
†The views expressed in this paper are those of the author and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the United States Government.
References
1. Bottoni CR, Smith EL, Berkowitz MJ, Towle RB, Moore JH. Arthroscopic versus open shoulder stabilization for recurrent anterior instability: a prospective randomized clinical trial. Am J Sports Med. 2006;34:1730-7.
2. DeBerardino TM, Arciero RA, Taylor DC, Uhorchak JM. Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Two- to five-year follow-up. Am J Sports Med. 2001;29:586-92.
3. Boileau P, Villalba M, Héry JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am. 2006;88:1755-63.
4. Rhee YG, Ha JH, Cho NS. Anterior shoulder stabilization in collision athletes: arthroscopic versus open Bankart repair. Am J Sports Med. 2006;34:979-85.
5. Kim SH, Ha KI, Cho YB, Ryu BD, Oh I. Arthroscopic anterior stabilization of the shoulder: two to six-year follow-up. J Bone Joint Surg Am. 2003;85:1511-8.
6. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000;16:677-94.
7. Owens BD, Dawson L, Burks R, Cameron KL. Incidence of shoulder dislocation in the United States military: demographic considerations from a high-risk population. J Bone Joint Surg Am. 2009;91:791-6.
8. Robinson CM, Howes J, Murdoch H, Will E, Graham C. Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. J Bone Joint Surg Am. 2006;88:2326-36.
9. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study. J Shoulder Elbow Surg. 1999;8:66-74.
10. Ozbaydar M, Elhassan B, Diller D, Massimini D, Higgins LD, Warner JJ. Results of arthroscopic capsulolabral repair: Bankart lesion versus anterior labroligamentous periosteal sleeve avulsion lesion. Arthroscopy. 2008;24:1277-83.
|
