Abstract & Commentary
Synopsis: To Magnusson and colleagues’ surprise, they found an unacceptably high rate of recurrent instability of 17% with long-term follow-up from open Bankart procedures. Source: Magnusson L, et al. Revisiting the open Bankart experience. A four- to nine-year follow-up. Am J Sports Med. 2002;30(6):778-782.
Traumatic anterior dislocations almost always result in detachment of the anterior inferior glenohumeral ligament and labral complex, termed a Bankart lesion. Historically, these have been fixed with an open reattachment of the capsulolabral complex with some degree of capsular shift to tighten any stretch in the capsule. A couple of frequently quoted papers by Rowe and Hovelius have recurrence rates of less than 5% with this open Bankart reconstruction.1,2 Unfortunately, it has been difficult for others to reproduce these results.
Magnusson and colleagues from Sweden critically looked at their results with open Bankart reconstructions in 54 patients. A standard open approach was used to reattach the capsule and labrum with about a 1-cm imbrication or shift of the capsule. These were fixed with standard suture anchor techniques to the front of the glenoid with the arm in 20° of external rotation.
All of the patients were evaluated by 3 experienced therapists who were not part of the surgical team, and, therefore, not at risk for surgeon observer bias by putting patients in a position in which they want to please their surgeons with good reports. Surprisingly, they found a high rate of recurrent instability, with 5 patients redislocating and 3 subluxating for a total recurrent instability rate of 17%. Some of these events first occurred several years after surgery. The minimum follow-up for this study was 4 years with a mean of nearly 6 years. Magnusson et al conclude that longer-term follow-up is needed with other studies to elicit a true recurrence rate with any stabilization procedure.
The patients also were noted, as other studies have found, to have decreased external rotation with an average loss of approximately 10°. However, 7 patients experienced a loss of much more motion than that. In addition to the loss of motion, the Constant shoulder scores and strength of rotation were significantly better on the noninjured side, and the activity level of patients decreased significantly. Magnusson et al conclude that they could not validate their hypothesis that an open Bankart would render a stable, well-functioning shoulder over the long term.
Comment by David R. Diduch, MS, MD
With the increasing popularity of arthroscopic Bankart reconstruction and a steady decrease in recurrence rate as techniques improve, it is helpful to see a critically performed study such as this that gives another look at the open Bankart experience. Magnusson et al are to be congratulated for trying to eliminate surgeon and observer bias in an otherwise retrospective study design. They can also be congratulated for following the patients over the long term and making a strong point for that in future studies. Several of the episodes of instability did not occur until 4-7 years after the index procedure. They also make a strong point to include subluxations as surgical failures.
The recurrent instability rate of 17% was unacceptably high for Magnusson et al to feel that the Bankart procedure predictably restores stability and a well-functioning shoulder. This certainly would be compounded by the loss of motion and recurrent pain reflected in the low Constant scores in these patients. It would be helpful to see similar long-term follow-up in the future as our arthroscopic experience grows with the newer techniques. I think this paper certainly heats up the debate of whether arthroscopic or open procedures are best. The long-held assumption that an open procedure would be better indicated for higher-demand contact athletes might not hold true if the recurrence rates are this high.
Dr. Diduch is Associate Professor, Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, VA.
References
1. Hovelius L, Thorling J, Fredin H. Recurrent anterior dislocation of the shoulder. Results after the Bankart and Putti-Platt operations. J Bone Joint Surg Am. 1979;61:566-569.
2. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: A long-term end result study. J Bone Joint Surg Am. 1978;60:1-16.
Synopsis: To Magnusson and colleagues surprise, they found an unacceptably high rate of recurrent instability of 17% with long-term follow-up from open Bankart procedures.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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