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© 1998 The Journal of Bone and Joint Surgery, Inc.
CorrespondenceTO THE EDITOR: We read "Bankart Repair for Anterior Instability of the Shoulder. Long-Term Outcome" (79-A: 850–857, June 1997), by Gill et al., with interest. The authors followed fifty-six patients for an average of 11.9 years (minimum, eight years) after a Bankart reconstruction for anterior instability. They stated in their Abstract that, as far as they knew, "there have been no studies on the long-term outcome of the Bankart procedure." Evidently, they were unaware of our paper, published in the American Journal of Sports Medicine2, in which we described the results of thirty-three Bankart reconstructions in thirty-one patients who were followed for an average of fifteen years (minimum, ten years). We demonstrated an association between the presence of degenerative glenohumeral arthrosis and limitation of external rotation with the arm abducted 90 degrees. We theorized that restricted external rotation may predispose the shoulder to degenerative arthrosis, although we were unable to demonstrate a causative relationship. This theory was proposed previously by Hawkins and Angelo1 and was supported by Trevlyn et al.3. We commend Gill et al. for their high rate of follow-up (79 per cent; fifty-six of seventy-one patients) in this retrospective study. However, we wonder why they did not more directly address the issue of degenerative arthrosis in their patients. Routine radiographs were not made unless "they were indicated clinically," and the authors did not indicate how many patients were evaluated radiographically. However, they noted that one patient had radiographic evidence of narrowing of the joint space and formation of osteophytes and that four patients had decreased range of motion and pain. It would be helpful to associate the findings of the physical examination of these patients with those on radiographs. The findings of Gill et al. support our observation that there is an association between loss of external rotation and degenerative arthrosis after Bankart reconstruction. As we noted in our Discussion2, restriction of external rotation in the presence of glenohumeral arthrosis is common, and a causative effect cannot be inferred. Clearly, however, a Bankart reconstruction that results in substantial loss of external rotation is associated with less than optimum subjective results and should be avoided. We encourage Gill et al. to study these patients radiographically during subsequent follow-up examinations in order to address these issues more closely. We maintain that Bankart reconstruction, when properly done, results in mild limitation of motion and that this limitation is not sufficient to cause late degenerative arthrosis. We agree that the Bankart procedure offers excellent restoration of stability to the shoulder, and we welcome additional long-term studies to help to determine whether or not the mild restriction of external rotation, which does occur, will be associated with progressive degenerative changes later in life.
Benjamin N. Rosenberg, M.D.: 150 Exchange Street, Middlebury, Vermont 05753 John C. Richmond, M.D.: Department of Orthopedics, Tufts-New England Medical Center, Boston, Massachusetts 02110 William N. Levine, M.D.: Department of Sports Medicine, University of Maryland, Baltimore, Maryland 21117
Dr. Gill, Dr. Micheli, Mr. Gebhard, and Mr. Binder reply: We agree with many of the points raised by Dr. Rosenberg et al. regarding the long-term outcome after Bankart repair. They correctly point out the high prevalence of good and excellent results after open Bankart repair as well as the association between the limitation of external rotation and degenerative arthrosis. As we reported, the chief symptoms of the four patients in our study who rated the result as fair or poor were decreased range of motion and pain. The patient who had a poor result had 0 degrees of external rotation, with radiographic evidence of narrowing of the joint space and formation of osteophytes. Routine radiographs were not made in our study. It has been our experience that a full series of radiographs of the shoulder is of little benefit and adds little to the clinical evaluation of a patient who is asymptomatic after a stabilization procedure. However, it does add unnecessary expense to the evaluation of a pain-free shoulder, exposes the patient to radiation, and requires the approval of the internal review board for a clinical investigation. All patients entered our study voluntarily; many had not been evaluated for more than ten years because they did not have symptoms. Thus, radiographic evaluation was performed only if it was indicated clinically by moderate or severe pain or the presence of glenohumeral crepitus on physical examination, or both. As we stated in our introduction, our study is, to the best of our knowledge, the first long-term outcome study of the Bankart procedure performed by one surgeon. The study by Rosenberg et al. included thirty-one patients who had been managed by four different surgeons. The operative procedures in that study did not appear to be uniform. In their description of perhaps the most critical part of the procedure, repair of the capsule to the glenoid rim, Rosenberg et al. stated that "the repair was performed with the humerus in 0–40 degrees of external rotation," without offering their indications for using one position rather than another. Moreover, some patients had a coracoid osteotomy to improve exposure, while others did not. Finally, there did not appear to be a standard rehabilitation protocol, as the authors stated that "post-operative immobilization was variable and ranged from approximately 1 to 4 weeks."
Thomas J. Gill, M.D.: Department of Orthopaedic Surgery, Massachusetts General Hospital, 32 Fruit Street, Boston, Massachusetts 02114 Lyle J. Micheli, M.D.: Department of Orthopedic Surgery, Division of Sports Medicine, Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115 Frank Gebhard, B.A.; Christian Binder, B.A.: Orthopedic Clinic, University of Mannheim, Mannheim 68167, Germany
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