Arthroscopic Bankart Reconstruction—A New Standard?
Abstract & Commentary
Synopsis: For the first time, an arthroscopic technique for shoulder stabilization had long-term success that is essentially equivalent to that reported for open Bankart reconstruction.
Source: O’Neill, DB. Arthroscopic Bankart repair of anterior detachments of the glenoid labrum. A prospective study. J Bone Joint Surg Am 1999;81(10):1357-1366.
Numerous authors have presented various techniques for arthroscopic stabilization of anterior shoulder instability. However, if followed longer than two years, none of the previous studies reported results that approached the 95% success of open Bankart reconstruction. O’Neill has now crossed that barrier in a well-designed prospective study of 41 patients treated arthroscopically who had experienced at least two dislocations and failed formal rehabilitation. During a mean follow-up of more than four years (range, 25 months-7 years), only two patients experienced subluxations and none had redislocations. Nearly half of the patients were football players, and all were athletic. All but one patient returned to their sport at the same level postoperatively.
The arthroscopic technique involved a variation of prior transglenoid methods. The capsule was pulled up before being transfixed with a passing pin used to pull a suture out the back of the scapula. A mulberry-style knot was tied on the outside, then pulled against the back of the glenoid. A second suture was passed through the glenoid below the first, and the two sutures were tied together anteriorly using an arthroscopic knot pusher. This was then repeated for at least one more pair of sutures.
Rigorous evaluation included radiographs, isokinetic strength testing, physical examination, and rating with the shoulder scale of Rowe and Zarins, as well as the scoring system of the American Shoulder and Elbow Surgeons. Good and excellent results were achieved in 90% of patients as determined by the Rowe and Zarins score, and 95% of patients as per the Shoulder and Elbow Surgeons’ score. Full range of motion and strength were regained by about half of the patients. Those patients with loose bodies, osseous Bankart lesions, or multiple dislocations indicative of more severe trauma tended to have more difficulty regaining strength or motion.
COMMENT BY DAVID R. DIDUCH, MS, MD
Previously reported arthroscopic stabilization techniques for shoulder instability yielded success rates of roughly 70-85%. Initial reports of higher success rates deteriorated with longer follow-up as patients regained motion and returned to athletics. Because open Bankart reconstruction results in 95% success even for recurrent dislocators, many surgeons are reluctant to recommend operative management of initial dislocations. This report by O’Neill is the first to report long-term success rates equivalent to those achieved by open methods. This paper is, therefore, likely to rekindle the debate about open vs. arthroscopic management and treatment of initial dislocations.
What is different about this study is the method of fixation. Transglenoid sutures are secured on the back of the scapula over bone, then tied over the labrum anteriorly. Other transglenoid methods tied sutures posteriorly over soft tissues that could necrose with time, possibly creating laxity in the construct. Why this new configuration would be better than suture anchors anteriorly is unclear and needs to be assessed with comparative biomechanical studies in cadaver models.
O’Neill’s study is well done, with careful, prospective follow-up that is complete and detailed. His results are excellent, even for patients returning to contact sports. However, these results may not be reproducible for a less-experienced arthroscopist, and one needs to be honest about his or her surgical abilities.
This paper probably should not alter management of initial dislocations, but may affect the decision to perform arthroscopic vs. open reconstruction. If patients who have recurrent anterior instability with documented Bankart lesions can have arthroscopic success equal to an open procedure, the reduced pain and recovery time tips the scale toward the less invasive method.
Hopefully, other authors will confirm these results, as should occur before a new technique enjoys widespread acceptance.
The historically accepted success rate for open Bankart reconstruction, against which newer arthroscopic techniques are compared, is:
a. 95%.
b. 90%.
c. 85%.
d. 80%.
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