Treatment of Anterior Shoulder Instability
Arthroscopic Bankart Repair vs Open Latarjet Procedure
Sir Arthur Blundel Bankart (1879-1951)
Was a British surgeon who first described repair of the attachment of the Labrum & its ligament attachment (Bankart lesion) in order to treat recurrent anterior (out the front) shoulder instability.
An arthroscopic Bankart repair involves placing anchors into the bone and pulling the sutures through the ligament and labrum and repairing the Bankart lesion.
She had a new shoulder dislocation from another injury one year later and had a recurrent Bankart lesion. This was treated with a Latarjet procedure.
Dr. Carer Rowe popularized the open Bankart repair and reported a very high success rate. This became a gold standard of repair in the USA during the 1980’s.
As Surgeons became more skilled in arthroscopic surgery in the 1990’s there was a gradual but dramatic movement to arthroscopic Bankart repair rather than open surgery.
Many surgical studies have now shown a recurrence rate of > 10% for arthroscopic Bankart repair. A number of risk factors have been suggested for these failures:
- < 20 years of age at time of surgery
- participation in competitive & contact sports
- Ligamentous laxity (looseness of shoulder joint)
- Bone loss on socket and on back of humeral head (Hill-Sachs lesion)
Recurrence of Instability after arthroscopic Bankart in collision athletes was 25% vs 12% if the repair was an open Bankart repair.
Arthroscopic Bankart repair in Adolescent athletes resulted in a recurrence rate of 21%, though 81% returned to sports participation.
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Dr. Jon JP Warner’s Quality Snapshot for Shoulder Instability Surgery (2013 – 2014)
Video of Patient After Latarjet Procedure
- Latarjet provides more reliable instability in active young individuals but does so with an added risk of complication over arthroscopic Bankart repair. (Dr. Warner’s Quality Snapshot)
- Latarjet provides earlier secure use of the shoulder than arthroscopic Bankart repair.
- Latarjet provides for range of motion, at least as good as arthroscopic Bankart repair (Video of Patient Range of Motion following Latarjet Procedure)
- Arthroscopic Latarjet procedures are evolving and are more difficult to perform than open latarjet procedures
- Dr. Warner performs more latarjet for traumatic shoulder instability than arthroscopic Bankart repair and most of these are for recurrent instability after a prior failed Bankart repair.
5 year experience for management of recurrent anterior instability: Arthroscopic Bankart vs Latarjet
- This is best suited to patients without bone loss and a Bankart lesion (labrum tear) with good tissue
- This allows for an arthroscopic repair (smaller incisions)
- This is associated with less complications of surgery than latarjet (Dr. Warner’s Quality Snapshot)
- It is associated with a lower recurrence rate than arthroscopic Bankart repair
- It allows for earlier use of the shoulder with potentially faster return to sports
- It can be performed as an outpatient procedure, the same as for arthroscopic Bankart repair
Remplissage
This is the french word for “to fill” and it refers to sewing the rotator cuff tendons (infraspinatus) into the Hill-Sachs lesion on the back of the humeral head (ball) in addition to performing a Bankart Repair. This is performed arthroscopically and some surgeons believe this will reduce risk of instability if there is bone loss on the front edge of the socket.
EVIDENCE: E.M. Wolf & A. Arianjam: Hill-Sachs Remplissage an arthroscopic solution for the engaging Hill-Sachs lesion: 2 – 10 year follow-up and incidence of recurrence. J Shoulder and Elbow Surgery 2014:814-20.
- 4.4% incidence of recurrent instability
- no reoperations or complicatoins
- Dr. Warner’s opinion: More issues with stiffness and recurrence than reported by the authors
Arthroscopic Latarjet Procedure
The arthroscopic Latarjet procedure is an evolving technique with a higher degree of difficulty than open Latarjet, and with a complication rate which is higher, at least with initial surgeon experience.
Bone Graft Reconstruction of Glenoid Socket
Bone graft reconstruction of the glenoid socket using bone graft from the patient’s iliac crest (area above the hip) or a cadaver graft. This is used in setting of severe bone loss of the glenoid socket anterior (front) edge which may occur after other failed surgery or simply as the result of many dislocations. This is most appropriate when bone loss is beyond that appropriate for the Latarjet procedure or when a Latarjet procedure has failed.
