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Bankart Repair for Anterior Instability of the Shoulder. Long-Term Outcome*

THOMAS J. GILL, M.D., LYLE J. MICHELI, M.D., FRANK GEBHARD, B.A.¶ and CHRISTIAN BINDER, B.A.¶, BOSTON, MASSACHUSETTS

Investigation performed at Children's Hospital Boston

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
Anterior instability of the shoulder is a commonly encountered entity in orthopaedic practice. The Bankart procedure is considered by many surgeons to be the treatment of choice for this condition. Despite its widespread popularity, there have been no studies on the long-term outcome of the Bankart procedure as far as we know. Sixty shoulders (fifty-six patients) that had been followed for a minimum of eight years after a Bankart procedure were evaluated for range of motion, stability, and strength according to the data form of the American Shoulder and Elbow Surgeons for examination of the shoulder. The results for the involved shoulder were compared with the findings for the contralateral, normal shoulder. All patients completed a questionnaire regarding the history of the instability of the shoulder, the level of participation in sports before and after the operation, the preoperative and postoperative level of pain, and whether the patient had ever sustained a dislocation that needed reduction by a physician. Information about the current ability of the patient to function at home, at work, and during sports also was requested. In addition, the patients were asked to rate the results of the operation and to indicate whether they would have the same procedure again for the same problem. At a mean of 11.9 years after the operation, the mean loss of external rotation was 12 degrees (range, 0 to 30 degrees) (p < 0.0001). There were no significant differences in forward elevation, abduction, or internal rotation between the involved shoulder and the contralateral, normal shoulder. One patient had crepitus on glenohumeral motion. Fifty-five of the fifty-six patients returned to the occupation that they had had preoperatively, without having to alter their activities. Twenty-eight patients had mild pain with strenuous activity, and one patient had pain at rest. Three patients had a dislocation of the involved shoulder because of a new traumatic event more than three years postoperatively. Fifty-two patients rated the result as good or excellent; three, as fair; and one, as poor. Fifty-four patients said that they would have a Bankart procedure performed again for the same problem. We present a new system for rating the shoulder that emphasizes function and is based specifically on the goals stated by the patients to be most important with regard to the shoulder. Using this system, we found that the Bankart procedure offers an excellent objective long-term outcome with a high degree of patient satisfaction.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion References

 
Operative procedures that have been used for the treatment of anterior instability of the shoulder include the Putti-Platt, Bristow, Magnuson-Stack, inferior capsular shift, Eden-Hybbinette, and Bankart procedures. The goal of each of these operations is to prevent recurrent instability of the glenohumeral joint. The Putti-Platt and Magnuson-Stack procedures seldom are performed because they are associated with complications, including limitation of external rotation and the development of degenerative changes within the glenohumeral joint. Use of the Bristow procedure is limited because it distorts the normal anatomy of the joint.

As a result of the problems associated with the other methods, the Bankart procedure currently is the most commonly performed operation for the treatment of traumatic anterior instability of the shoulder. Advocates of the procedure argue that it is the only operation that corrects the primary pathological defect involved in anterior instability of the shoulder, the so-called Bankart lesion¹. A Bankart lesion is found in as many as 85 per cent of dislocations^12,16,17, most commonly in the two to six o'clock position in the right shoulder and in the six to ten o'clock position in the left shoulder¹².

Despite the popularity of the Bankart repair, we know of no studies of the long-term outcome and the functional results of the procedure. The relatively short-term results have been reported in several studies^9,16. To our knowledge, we are the first to examine the long-term outcome of the Bankart procedure performed by one surgeon. In addition, we present a system for rating the results of operative procedures for instability of the shoulder.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
We reviewed the charts of ninety-one consecutive patients who had had a Bankart procedure between 1978 and 1986. All of the patients were managed by one surgeon (L. J. M.). Patients were excluded if they had multidirectional instability or had had a Bankart procedure performed after previously failed treatment for anterior instability—that is, if they had had revision of a previous Putti-Platt or capsular shift procedure. Seventy-one patients met our requirement for a minimum duration of follow-up of eight years.

Evaluation of the patients consisted of review of the chart and a follow-up examination performed by one of us (T. J. G.). The shoulder was tested for range of motion, stability, and strength, according to the data form of the American Shoulder and Elbow Surgeons for examination of the shoulder¹⁵. The results for the involved shoulder were compared with the findings for the contralateral, normal side. In addition, all patients were requested to complete a questionnaire (Table I) regarding the history of the instability of the shoulder, the level of participation in sports both before and after the operation, the preoperative and postoperative level of pain, and whether the patient had ever had a dislocation that needed reduction by a physician. The current functional status of the patient at home, at work, and during sports also was assessed. Radiographs of the shoulder were made only if they were indicated clinically by the level of pain or the presence of crepitus with glenohumeral motion on examination, or both. The patients also were asked to rate the results of the operation and to indicate if they would have the procedure again for the same problem. These data were collected for fifty-six patients (sixty shoulders) who formed the basis of this investigation.

Operative Procedure
The patient is placed in the semi-Fowler position on the operating table with the affected shoulder and the entire extremity draped free. An anterior deltopectoral approach is used. The interval between the deltoid muscle and the pectoralis major is identified and opened. The cephalic vein is identified and retracted laterally with the deltoid muscle. Dissection is carried down to the clavipectoral fascia, where an incision is made lateral to the short head of the biceps and the coracobrachialis muscle. These muscles then are retracted medially, exposing the underlying subscapularis. Care is taken during retraction not to injure the musculocutaneous nerve. The coracoid process is not osteotomized. Adequate exposure of the anterior aspect of the shoulder is attained with sufficient dissection superiorly to the margin of the coracoid.

The mid-portion of the subscapularis is exposed. A series of three or four number-1 permanent sutures is placed in a figure-of-eight fashion at the muscle-tendon junction of the subscapularis. Anterior traction is applied to them, allowing division of the tendinous insertion of the subscapularis while preserving the anterior aspect of the capsule of the glenohumeral joint. A combination of blunt and sharp dissection then is used to expose the entire anterior extent of the capsule under the superior and inferior leafs of the subscapularis muscle.

The placement of the incision in the anterior aspect of the capsule of the shoulder is crucial because it determines the ultimate range of motion and mobilization of the shoulder. A gently curved vertical incision is made with the shoulder reduced against the glenoid. Adequate reduction is achieved by flexing and rotating the shoulder. Then, the upper extremity is returned to a position of external rotation that is one-half the range of external rotation of the contralateral extremity. For example, when the contralateral extremity has 90 degrees of external rotation, the involved shoulder is placed in 45 degrees of external rotation. The capsule is placed under tension with a forceps, and the portion of the capsule directly anterior to the glenoid rim is marked with electrocautery. Then, a gently curved incision is made, extending superiorly and inferiorly from this point, parallel to the glenoid labrum. The length of the lateral leaf of the capsule from its insertion on the humerus to the cut margin determines the external rotation that is attainable postoperatively.

Retractors are placed within the shoulder, and the entire shoulder is examined. Systematic probing of the entire labrum also is performed. Younger individuals have a higher prevalence of osteochondral loose bodies and a lower prevalence of Bankart lesions.

A series of mattress sutures is placed from the superior to the inferior margin of the labrum. These are passed beneath the labrum from inside the joint to outside the joint and then are passed back again from outside to inside. The sutures are secured with a series of hemostat clamps. If any redundant capsule is evident at the inferior margin of the joint, it is marked with a separately placed suture at the apex of the redundancy. This separate suture is called the swing stitch and is used to plicate any redundancy in the inferior part of the capsule by advancing this tissue superiorly on the capsulolabral repair.

At the time that these operations were performed, suture-anchor techniques were not available. Therefore, if a substantial Bankart lesion was found, the anterior aspect of the glenoid rim was drilled superior and inferior to the margin of the lesion. Number-1 or 2 permanent sutures were placed through these drill-holes in order to reattach the incised capsule. If other sites of labral detachment were located, the underlying bone was carefully curetted to remove any overlying fibrocartilage that may have formed.

Next, beginning at the superior margin of the repair, the mattress sutures that were placed in the labrum are sequentially placed through the lateral cut margin of the capsulotomy. Each suture is placed two millimeters from the cut edge of the capsule and three millimeters apart from the previous suture.

When all sutures have been passed through the lateral aspect of the capsule and secured with hemostats, the retractors are removed and the shoulder is internally rotated and reduced with flexion of the shoulder and the elbow. These sutures are tied down in sequence from superior to inferior.

A second layer of closure is performed by suturing the free medial margin of the redundant medial aspect of the capsule back to the newly anchored lateral aspect of the capsule from its superior margin to its inferior margin. If it is necessary, additional sutures are placed at the margin of the redundant fold, adjacent to the apex.

Finally, the medial portion of the detached subscapularis is reattached to its site of resection with use of the previously placed figure-of-eight sutures.

At the completion of the procedure, the subcutaneous tissue is closed with interrupted sutures and the skin is closed with a running intracutaneous stitch. A drain usually is not used.

Postoperative Rehabilitation
Postoperatively, the shoulder is supported in a sling with the arm at the side. The patient is taught an initial program of exercises to be performed at home for the first two weeks. This program consists of six-direction isometric contractions of the muscles into flexion, extension, abduction, adduction, internal rotation, and external rotation. The patient is instructed to do at least ten shoulder shrugs three times a day. Finally, a series of gentle rotational exercises consisting of pendulum maneuvers and flexion and extension of the elbow are begun.

At the two-week postoperative examination, the wound is inspected and the stitches are removed. At that time, a formal rehabilitation program is initiated under the direction of a physical therapist. Two to four weeks postoperatively, emphasis is placed on progressively restoring an active and passive range of motion. Gentle progressive strengthening exercises are begun after the fourth postoperative week. Patients are allowed to advance into a program of full resistance exercises at eight weeks postoperatively. Light activity, including swimming, is generally begun at that time. Most patients are allowed to return to non-contact sports by four months and to contact sports by six months postoperatively.

Statistical Methods
The data were analyzed with use of the Mann-Whitney non-parametric U test.

	Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
The study group consisted of thirty-nine male and seventeen female patients. Four patients had a bilateral procedure, so there was a total of sixty shoulders in the study. The dominant shoulder was involved in forty-four patients and the non-dominant shoulder, in sixteen. Fifty-one shoulders had a history of injury. Fifty-three shoulders had had at least one preoperative dislocation that needed reduction by a physician. Six patients had a first-degree relative who had had a dislocation of a shoulder.

The mean age at the time of the operation was 21.4 years (range, sixteen to forty-two years). A Bankart lesion was identified in thirty-nine (65 per cent) of the sixty shoulders. One patient had a Hill-Sachs lesion and a glenoid deficiency large enough for a bone-grafting procedure to prevent recurrent instability to be considered. The mean duration of follow-up was 11.9 years (range, eight to sixteen years).

Physical Examination
The contralateral shoulder served as the control for each patient except for those who had had a bilateral procedure. On inspection of the shoulders, two patients had atrophy of the supraspinatus muscle on the affected side. Three shoulders had tenderness anterior to the acromion. The mean range of motion was determined for both the involved shoulder and the contralateral shoulder (Table II), and no significant differences were found with respect to internal rotation, abduction, and forward elevation. However, there was a mean difference of 12 degrees (range, 0 to 30 degrees) of external rotation (p < 0.0001) (Table II). One shoulder had crepitus with glenohumeral motion, and true anteroposterior and axillary radiographs demonstrated narrowing of the joint space and formation of osteophytes.

Assessment of Symptoms and Functional Status by the Patient
In order to assess the preoperative and postoperative level of pain and of sports activity, episodes of recurrent dislocation of the shoulder, and the functional results, a questionnaire was completed by all patients (Table I).

Pain
Patients were asked to evaluate the presence or absence of postoperative pain with use of a 5-point scale. The complete absence of pain with all activity was given a score of 0 points. Mild, moderate, or severe pain related to activity was rated 1, 2, or 3 points, respectively. Moderate pain at rest was rated 4 points and severe pain at rest, 5 points.

Twenty-nine shoulders had pain, mostly mild with strenuous activity. The mean score for pain for those patients was 1.7 points. One patient used a narcotic (codeine) intermittently to control the pain.

Return to Sports
Each patient was questioned with regard to the level and frequency of participation in sports both before and after the Bankart procedure as well as the current level of sports activity. One tennis player who had had the operation when he was seventeen years old was unable to return to an elite level of competition because he had diminished external rotation when he served the ball and pain when he played the game. However, he continued to play on a recreational level without difficulty. Ten other patients stated that they were not currently involved in athletic activities at the same competitive level as they had been preoperatively, but the change in level was by choice and not because of any issues related to the shoulder.

Return to Work
Fifty-five (98 per cent) of the fifty-six patients returned to the occupation that they had had preoperatively without having to alter their activities substantially. One patient, who had been receiving Workers' Compensation because he had sustained an injury at a construction site, was unable to return to his job and had changed his occupation.

Recurrent Dislocations
Three patients had a dislocation of the involved shoulder after the index Bankart procedure. One patient had sustained a reinjury of the shoulder three years postoperatively in a fall from a motorcycle during a moto-cross racing event. The second patient, a football player, sustained the dislocation four years postoperatively, after landing on the shoulder while making a tackle. The third patient was an avid kick-boxer who sustained the reinjury nine years postoperatively during a match. At the time of the follow-up examination, these were all isolated dislocations. None of the shoulders needed a repeat operation, and none of the patients had substantial pain.

Functional Results
Part of the questionnaire was used to assess the ability of the patients to perform activities of daily living with use of the involved shoulder (Table III). The activities are grouped according to the need for internal rotation, forward elevation or external rotation, or stress loading. Combined activities are also included.

Development of a Shoulder-Rating System
Each patient was asked to indicate what aspects of the shoulder or its function were most important to him or her. On the basis of those responses, we developed a shoulder-rating system, and all shoulders were evaluated with use of this system (Table IV). The system combines the patient's assessment of the functional results as well as the level of pain and the physician's evaluation of the range of motion and the stability of the shoulder. The most frequently stated priority of the patients was the ability to function at a high level during a variety of activities of daily living and recreation. The next priority was an adequate range of motion, especially external rotation. The range of external rotation after a Bankart repair in the present study ranged from 0 to 30 degrees to 0 to 45 degrees in patients who had an excellent result, from 0 to 20 degrees to 0 to 30 degrees in patients who had a good result, from 0 to 10 degrees to 0 to 20 degrees in patients who had a fair result, and 0 degrees in the one patient who had a poor result. Patients stated that adequate (maximum) motion was more important than stability. The last priority was the desire to be free of pain.

Assessment of the Over-All Long-Term Results
Each patient was asked to evaluate the long-term result of the operation. Forty-three patients rated the result as excellent; nine, as good; three, as fair; and one, as poor. One of the three patients who rated the result as fair was receiving Workers' Compensation and stated that he was still involved in physical therapy. He reported that he was dissatisfied because the affected shoulder felt "different" than the contralateral side. The second patient reported decreased external rotation. The shoulder had 20 degrees of adduction, and the score for function was 4.6 points. The third patient did not give a reason for the assessment.

The one patient who rated the result as poor reported that he had pain and decreased motion of the shoulder. Preoperatively, he had no history of dislocation and was found to have generalized ligamentous laxity. At fourteen years after the index operation, he had had two additional procedures for lengthening and release of the anterior aspect of the capsule and the subscapularis. Early degenerative changes were seen on radiographs, and the patient was taking codeine intermittently for control of pain.

Fifty-four (96 per cent) of the fifty-six patients stated that they would have a Bankart procedure performed again for the same problem. Two patients said that they would prefer simply to try to rehabilitate the shoulder and to decrease the level of physical activity.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
Anterior instability of the shoulder is a common disorder, and the variety of treatment options range from rehabilitation of the rotator cuff, deltoid, and periscapular muscles to operative stabilization. The Bankart procedure is considered by many surgeons to be the treatment of choice for anterior instability, particularly if the disorder results from a traumatic etiology, because the repair directly addresses the torn or attenuated capsule or labrum, or both, at the glenoid rim^{1,8,10,14,16,17}.

Despite the popularity of the Bankart procedure and the many reports on it in the literature, little has been written regarding the long-term results and the functional outcome. In a ten-year follow-up study of 176 patients (183 shoulders) who had been managed for instability of the shoulder, Morrey and Janes reported a rate of recurrence of 11 per cent (twenty patients). However, 128 of the patients (132 shoulders) had had a Putti-Platt procedure, thirty-three patients (thirty-five shoulders) had had a combination of a Putti-Platt and a Bankart procedure, four patients (four shoulders) had had a modified Bankart procedure, and only eleven patients (twelve shoulders) had had a simple Bankart repair. In addition, few of the patients had had a recent physical examination and little data were provided on the functional outcome. The number of surgeons involved in the series was not specified. Recurrent instability was associated with youth, athletic activity, inadequate immobilization, a history of dislocation of the contralateral shoulder, and family history.

In one of the more commonly cited studies on the results of the Bankart procedure, Rowe et al.¹⁶ reported on 145 patients (146 shoulders) who were followed for a mean of six years (range, one to thirty years). On the basis of a rating system presented in that report, 108 (74 per cent) of the patients had an excellent result; thirty-three (23 per cent), a good result; and four (3 per cent), a poor result. Five patients (3 per cent) had a recurrence, and four of the recurrences occurred within two years postoperatively. Of the 124 patients who had a follow-up examination for that study, 69 per cent (eighty-six) had so-called full external rotation. No formal postoperative program of rehabilitation was prescribed, and the authors indicated that a return of 75 to 100 per cent of full motion and strength could be expected after the Bankart procedure. No degenerative changes were seen on radiographic examination. Ten (33 per cent) of the thirty patients who had involvement of the dominant shoulder and who had participated in a sport that required throwing before the operation were able to throw, serve in tennis, or swim with an overhead stroke as hard as they had before the operation. Only one of forty-six patients in whom the dominant shoulder was involved was not able to return to sports activities.

The rates of recurrence of instability as well as the etiologies and treatments for recurrences have been examined in other studies^4,6,9,17,19. Hovelius et al.⁹ reported a rate of recurrence of 2 per cent (one shoulder) in a study of forty-six shoulders that had had Bankart procedures performed by nine different surgeons. Causes for recurrent instability after a Bankart procedure have included a new Bankart lesion or an attenuated capsule and a scarred subscapularis that was considered to be dysfunctional as a secondary restraint^6,9,17,19. In other studies, the etiologies for recurrent instability have included a wide rotator interval or a large Hill-Sachs lesion^4,17. A successful result was achieved in 92 per cent (twenty-two) of twenty-four shoulders that had a revision Bankart procedure, with no degenerative changes noted intraoperatively at the time of the revision¹⁷.

In our study, the long-term result of the Bankart procedure for the treatment of anterior instability of the shoulder was good or excellent for fifty-two (93 per cent) of fifty-six patients—according to both objective criteria and, equally important, the patients' subjective evaluation. Fifty-five (98 per cent) of our fifty-six patients returned to their preoperative occupation and level of activity, while only one of the forty-seven patients involved in competitive athletics was unable to return to the preoperative level of sports activity because of pain in the shoulder with overhead activity. Fifty-four (96 per cent) of the fifty-six patients stated that they would have a Bankart procedure performed again for the same problem.

Postoperative instability was not a significant problem in the present investigation, with the numbers available. Three (5 per cent) of sixty shoulders had a recurrent dislocation, but none of them needed an additional operation. Each recurrence was the result of a new traumatic event and probably not a consequence of the stabilization procedure. There were no episodes of instability within two years postoperatively, in contrast to the findings of Rowe et al.¹⁶.

The most common problems reported by the four patients who rated the result as fair or poor were a decreased range of motion and intermittent pain—not instability. When asked what they would have wanted done differently with regard to the operation, all four patients would have preferred a looser shoulder. None of the four patients were athletes who played at a high level of competition, and each stated that, in retrospect, they would have preferred altering the level at which they participated in sports in order to accommodate a more lax shoulder, with the understanding that they could have a repeat stabilization if the shoulder remained too loose. This option should be considered if capsular tightening or capsular shift is performed in addition to a true Bankart repair.

Modifications of the classic Bankart technique have been attempted in order to gain stability without compromising motion, and they have had varying degrees of success^{2,10,11,18,20,21}. Arthroscopic techniques have been reported to have a rate of complications of 42 per cent (twenty-one of fifty)⁷. The rate of recurrence was 13 per cent (four of thirty shoulders) in a study in which the Bankart lesion was repaired with a single interosseous extra-articular suture and a longitudinal capsulotomy to prevent shortening and to allow a shift¹¹. In a study of the so-called inside-out Bankart procedure, the rate of recurrence was 9 per cent (six of sixty-nine shoulders) and 77 per cent (fifty-three) of the shoulders were asymptomatic when the capsule and the subscapularis had been incised together just medial to the biceps².

We perform a modified Bankart procedure. The upper extremity is held in external rotation equal to one-half the external rotation of the contralateral extremity, and the capsulotomy is performed in order to minimize the risk of overtightening the capsule during the repair. A careful dissection between the subscapularis and the capsule during the exposure also is performed in order to minimize the amount of postoperative scarring between the two structures, which may play a role in loss of motion. When the subscapularis has been repaired, the upper extremity is moved through a complete range of motion and the limits are carefully recorded. This arc of motion serves as the guideline for an early postoperative program of rehabilitation, thereby minimizing the risk of damage to the repair while inhibiting postoperative scarring and the formation of constrictures. Suture anchors, which are now available, are used if a Bankart lesion is present.

Most of our patients indicated that they wished that they had worked harder at physical therapy in the first six months postoperatively. Those who tried to perform rehabilitation on their own said that it was difficult to stay fully motivated during the process. Therefore, understanding the need to keep health-care costs at a minimum, we recommend at least six weeks of formal physical therapy, consisting of two or three sessions per week, in order to work on motion according to the guidelines determined intraoperatively. Thereafter, the patient should have one session of physical therapy each week for six weeks in order to introduce strengthening exercises and to continue to improve forward elevation and external rotation.

Several shoulder-rating systems have been proposed as a means of objectively evaluating the glenohumeral joint^3,5,15,16. However, systems such as that of Rowe et al.¹⁶ emphasize stability (50 points) more than function and pain (30 points) or motion (20 points). Even with a carefully performed Bankart repair, loss of motion appears to be a greater risk than recurrent instability. Most patients in our study stated at the long-term follow-up examination that their primary interests were to be able to perform the activities of daily living and their occupation without pain and to have minimum limitation in the range of motion. We found a direct association between the range of motion after a Bankart repair and the quality of the results as determined with use of our rating system. Few of our patients were still competing in athletic activities at an elite level, and most of the patients who had a good, fair, or poor result indicated that they would be willing to adjust their level of activity in exchange for more motion and less pain. Thus, we present a modified shoulder-rating system that places greatest emphasis on pain-free function followed by stability and motion (Table IV). With use of this system, the mean score for the patients who had an excellent subjective result was 93 points. The mean scores for good, fair, and poor results were 82, 65, and 58 points, respectively.

Treatment of anterior instability of the shoulder is a balance between gaining glenohumeral stability and minimizing loss of glenohumeral motion. The choice of treatment must be individualized on the basis of the patient's occupation and level of participation in sports as well as on the degree of instability of the shoulder. The present study shows that the Bankart procedure offers excellent objective long-term results with a high degree of patient satisfaction.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Winner (T. J. G.) of The American Orthopaedic Association-Zimmer Travel Award for Orthopaedic Research, 1996.

Department of Orthopaedic Surgery, Massachusetts General Hospital, 32 Fruit Street, Boston, Massachusetts 02114.

Department of Orthopedic Surgery, Division of Sports Medicine, Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115.

¶Orthopedic Clinic, University of Mannheim, Mannheim 68167, Germany.

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