Article

Comparison of Curved and Straight Anchor Insertion for Bankart Repair

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

The quality of Bankart repair may be compromised by the presence of glenoid perforation during suture anchor placement. The purpose of this study was to compare the rate of glenoid perforation and biomechanical strength of antero-inferior suture anchors placed with a curved vs a traditional straight technique through an anteroinferior portal. Ten bilateral pairs of fresh human cadaveric shoulders were randomized to either a curved or a straight suture anchor insertion technique. An anteroinferior portal was used to place a 1.5-mm soft anchor in the anteroinferior glenoid (5:30 position for right shoulders). Anatomic dissection was performed, and the maximum load of each anchor was measured using a materials testing system. The overall rate of glenoid perforation by the anteroinferior anchor was 50%. The rate of glenoid perforation was 40% in the straight group and 60% in the curved group (P=.41). The median maximum load was 86 N in the straight group and 137 N in the curved group (P=.23). The median maximum load of the anchors that did perforate the glenoid was 102 N and of those that did not was 118 N (P=.72). The mode of failure was suture anchor pullout in all except one specimen. The curved guide was not superior to the traditional straight guide in terms of the rate of glenoid perforation or the maximum load of the suture anchors. Anterior cortical perforation of the glenoid during anteroinferior suture anchor placement is common with both techniques. [Orthopedics. 2019; 42(2):e242-e246.].

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

Article
Purpose The purpose of this systematic review was to investigate variability in biomechanical testing protocols for laboratory-based studies using suture anchors for glenohumeral shoulder instability and SLAP lesion repair. Methods A systematic reviewing of Medline, Embase, Scopus and Google Scholar using Covidence software was performed for all biomechanical studies investigating labral-based suture anchor repair for shoulder instability and SLAP lesions. Clinical studies, technical notes or surgical technique descriptions, or studies treating glenoid bone loss or capsulorraphy were excluded. Risk of bias (ROB) was assessed with the ROBINS-I tool. Study quality was assessed with the QUACS (Quality Appraisal for Cadaveric Studies). Heterogeneity was assessed with the I² statistic. Results A total of 41 studies were included. ROB was serious and critical in 27 studies, moderate in 13, and low in one; six studies had high quality, 21 good quality, 10 moderate quality, 2 low quality, and 2 very low quality. 31 studies used and 22 studies included cyclic loading. Angle of anchor insertion was reported by 33 studies. The force vector for displacement varied. The most common directions were perpendicular to the glenoid (9), and antero-inferior or anterior (8). The most common outcome measures were load to failure (35), failure mode (23), and stiffness (21s). Other outcome measures included load at displacement, displacement at failure, tensile load at displacement, translation, energy absorbed, cycles to failure, contact pressure, and elongation. Conclusion This systematic review demonstrated a clear lack of consistency in those cadaver studies that investigated biomechanical properties following surgical repair with suture anchors for shoulder instability and SLAP lesions. Testing methods between studies varied substantially with no universally applied standard for preloading, load to failure and cyclic loading protocols, insertion angles of suture anchors, or direction of loading. To allow comparability between studies standardisation of testing protocols is strongly recommended. Clinical relevance The demonstrated heterogeneity between testing protocols for basic science biomechanical studies makes between study comparisons difficult. Standardised testing protocols are recommended.
Article
Full-text available
Background: Injuries to the glenoid labrum frequently require repair with anchors. Placing anchor devices arthroscopically can be challenging, and anchor malpositioning can complicate surgical outcomes. Purpose: To determine the safe insertion range and optimal insertion angle of glenoid labral anchors at various positions on the glenoid rim and to establish surgical guidelines that minimize risk of anchor perforation. Study design: Descriptive laboratory study. Methods: Three-dimensional computed tomography scans of 30 normal cadaveric specimens were obtained. A virtual model of a generic labral anchor was inserted into the rim of the glenoid at the clockface positions represented by 12:00, 1:30, 3:00, 4:30, 6:00, 7:30, 9:00, and 10:30. At each position, the safe insertion range was the maximal range measured, and the optimal insertion angle was identified as the angle between the bisector of the safe insertion range and the glenoid face. Results: Progressing in the clockwise direction, beginning at the 12:00 position, the safe insertion ranges (mean ± SD ) were 55.9° ± 10.6°, 63.6° ± 17.6°, 47.7° ± 9.1°, 46.1° ± 8°, 73.9° ± 9.7°, 40.9° ± 6.5°, 40.4° ± 7.4°, and 39.9° ± 7.1°, respectively. The optimal insertion angles were 47.9° ± 7.6°, 53.1° ± 10.9°, 35.0° ± 4.4°, 42.4° ± 4.9°, 60.9° ± 8.4°, 36.6° ± 5.9°, 31.2° ± 4.9°, 34.8° ± 4.6°, respectively. Conclusion: Optimal insertion angles and safe insertion ranges varied significantly with respect to the position on the glenoid face. The safe insertion range and optimal insertion angle were found to be wider at the anterior glenoid as compared with the posterior glenoid. A posterolateral insertion angle was safer than an anterior insertion angle at the 10:30 position. Clinical relevance: Proper arthroscopic technique resulting in anchor insertion at the correct angle, depth, and location will prevent anchor-related glenohumeral complications such as glenoid perforation, cartilage damage, persistent pain, decreased range of motion, and failure of the reconstruction.
Article
Full-text available
The glenohumeral joint is the most frequently dislocated major joint, and most cases involve an anterior dislocation. Young male athletes competing in contact sports are at especially high risk of recurrent instability. Surgical timing and selection of surgical technique continue to be debated. Full characterization of the injury requires an accurate history and physical examination. Diagnostic imaging assists in identifying the underlying anatomic lesions, which range from no discernible lesion to significant bone loss of the glenoid or humeral head and/or capsulolabral stretching or avulsion from the glenoid or humerus. Historically, open Bankart repair has been considered to be the standard method of managing capsulolabral injuries, but comparable results have been achieved with arthroscopic techniques. In the setting of anterior glenoid bone loss >20% of the articular surface, iliac crest bone grafting or coracoid transfer via the Bristow or Latarjet procedures has demonstrated satisfactory outcomes. Favorable results have been reported with bone grafting or remplissage for engaging Hill-Sachs lesions and those that affect >30% of the humeral circumference.
Article
Full-text available
There are not many reports in the literature about the long-term outcomes in terms of recurrence and degenerative changes after arthroscopic capsulolabral reconstruction for anterior shoulder instability. The aim of this study was to evaluate long-term follow-up (minimum 10 years) of arthroscopic suture-anchor repair for traumatic unidirectional anterior instability, with special emphasis on the radiological evidence of arthritis and clinical outcome. Case series; Level of evidence, 4. Forty-two patients (43 shoulders) treated at our institute from 1995 to 1997 were included in the study. Thirty patients (31 shoulders) were available for clinical and radiological examination (71%). The mean follow-up was 10.9 years (range, 9.8-14.3 years). Patients were evaluated preoperatively and after surgery using the University of California, Los Angeles (UCLA), Simple Shoulder Test (SST), and Rowe score. Patient satisfaction was determined by asking the patients if they would do this operation again. Radiological outcome was used to evaluate the incidence and grade of arthritis according to the Samilson-Prieto classification. At the final follow-up examination, 5 patients (16%) reported an atraumatic recurrent instability, while 2 recurrences (7%) occurred after a major injury. Three of the 7 recurrences occurred 6 years after surgery. All of the patients in the recurrence group except 1 were contact or overhead athletes. Twenty-six patients were satisfied (84%) with the outcome. The SST showed an improvement of shoulder function in 23 cases, the UCLA score improved from 21.8 to 32.1, and the Rowe score showed excellent or good results in 77.3% of cases. Twenty-two patients (71%) were able to return to their preoperative sports level. Radiographic findings showed 9 cases with mild arthritis (29%) and 3 cases with moderate arthritis (10%). The recurrence rate deteriorated with time. Involvement in contact sports and overhead activities appears to be a risk factor for recurrence of instability, although this could not be proved statistically with the numbers available, whereas age, gender, and number of preoperative dislocations did not reveal any correlation with recurrence. Degenerative changes of the glenohumeral joint were noted but had no significant effect on the clinical outcomes.
Article
Full-text available
Traumatic anterior-inferior shoulder joint dislocations are common injuries among the young athletic population. The aim of this study was to assess which factors, including concomitant injury (rotator cuff tears, superior labral anterior posterior [SLAP] lesions), patient age, and fixation methods, led to redislocation after arthroscopic stabilization. There are several risk factors for the outcome after arthroscopic anterior-inferior glenohumeral stabilization. Cohort Study; Level of evidence, 3. Between 1996 and 2000, 221 patients were treated with arthroscopic stabilization for anterior-inferior shoulder dislocation. Of these 221 consecutive patients, 190 (140 male, 50 female) with an average age of 28.0 years (range, 14.4-59.2 years) were available for follow-up (average follow-up, 37.4 +/- 15.8 months). Fixation methods were FASTak (n = 138), Suretac (n = 28), or Panalok (n = 24) anchors. Concomitant SLAP lesions were seen in 38 of 190 cases (20%). Redislocation rates varied between anchor systems (FASTak, 6.5%; Suretac, 25%; Panalok, 16.8%). Superior labral anterior posterior lesions, when treated, did not influence clinical outcomes or redislocation rate. A concomitant rotator cuff tear did not influence redislocation rate. Postoperative outcomes (Rowe score, Constant score, American Shoulder and Elbow Surgeons [ASES] shoulder index, 12-item questionnaire) in patients with a partial tear were also not altered. On the other hand, the redislocation rate correlated with patient age and number of prior dislocations. Return to sports at preinjury level was possible in 80% of cases. Arthroscopic repair of anterior-inferior instability using the 5:30-o'clock portal is dependent on anchor type and can show good to excellent results. Because of several coinjuries in anterior-inferior instability, an arthroscopic approach may be required to identify and treat such lesions.
Article
Full-text available
The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. The results continue to improve with the advancements made in instrumentation and technique. This study aims to evaluate the outcome of arthroscopic Bankart repair with the use of suture anchors for cases that were followed-up for at least two years from the date of surgery. This was a consecutive series of 40 shoulders in 37 patients who underwent arthroscopic Bankart repair with suture anchor. The mean age at the time of operation was 26.3 years. The patients were assessed with two different outcome measurement tools (the University of California at Los Angeles [UCLA] shoulder rating scale and simple shoulder test [SST] score). The mean duration of follow-up was 30.2 months. The recurrence rate, range of motion, and postoperative function were evaluated. The two shoulder scores significantly improved after surgery (p-value is less than 0.05). According to the UCLA scale, 37 shoulders (92.5 percent) had excellent or good scores, one shoulder (2.5 percent) had a fair score, and two (five percent) had poor scores. All 12 components of SST showed improvement, which was statistically significant. Overall, the rate of postoperative recurrence was 7.5 percent (three shoulders). All patients either maintained or demonstrated improvement of range of motion. There was no loss of external rotation range of motion postoperatively. Arthroscopic Bankart repair with the use of suture anchors is a reliable treatment method that can provide a good clinical outcome with excellent postoperative shoulder motion and low recurrence rate.
Article
Full-text available
Arthroscopic treatment of anterior shoulder dislocation has become possible through improvements in instruments and techniques. To prospectively evaluate results of arthroscopic Bankart repairs at a minimum 2-year follow-up for patients with histories of shoulder dislocation and an anterior-inferior labral tear at the time of diagnostic arthroscopy. Case series; Level of evidence, 4. A consecutive series of 85 patients (70 men, 15 women; mean age, 26 years) with Bankart lesions were treated with arthroscopic repair using suture anchors; 18 patients (27%) had extension of the labral injury into the superior labrum affecting some or all of the biceps anchor. Anchors were loaded with no. 2 nonabsorbable braided suture and placed 2 mm into the edge of the glenoid surface. A low anterior (5-o'clock) portal through the subscapularis tendon was used in all patients; 72 patients were evaluated at a minimum of 2 years postoperatively (mean, 46 months). Seven patients (10%) experienced recurrent instability after repair. Four patients had redislocations; 3 experienced recurrent subluxations. One patient had pain with the apprehension test without a clear history of recurrent instability. Of 18 collision athletes, 2 had dislocations at 22 and 60 months postoperatively. There were no complications, including no neurologic deficits. Clinical strength testing of the subscapularis muscle was normal in all patients. The mean Rowe score was 88 of 100 points, with 90% excellent or good results. Simple Shoulder Test responses improved from 66% positive preoperatively to 88% positive postoperatively. The American Shoulder and Elbow Surgeons scoring index averaged 92 of 100 points postoperatively. Pain analog scales improved from 5.5 preoperatively to 0.35 postoperatively on a 10-point scale. SF-12 scores improved for physical function. Patient satisfaction was rated 8.9 on a 10-point visual analog scale. Bankart repairs performed arthroscopically using properly implanted suture anchors and nonabsorbable sutures and in which associated pathoanatomy is addressed demonstrate low recurrence rates (10%) similar to historical open controls.
Article
Purpose: The purpose of this study was to compare the risk of glenoid perforation during SLAP repair for suture anchors placed through an anterolateral portal versus a posterolateral portal of Wilmington. Methods: Ten bilateral cadaveric shoulders were randomized to suture anchor placement through an anterolateral portal on one shoulder and a posterolateral portal on the contralateral shoulder. Anchors were placed into anterior, posterior, and far posterior positions on the glenoid rim (1 o'clock, 11 o'clock, and 10 o'clock positions for right shoulders). The shoulder was then dissected, and the distance from the suture anchor tip to the nerve was measured if perforation occurred. The maximum load and failure mechanism of each anchor was assessed with a materials testing system machine. Results: Only 2 of 20 anchors placed in the posterosuperior glenoid through the posterolateral portal perforated compared with 16 of 20 of the anchors placed through the anterolateral portal (P < .05). The mean distance from the perforated anchor tip to the suprascapular nerve was 2.5 ± 1.4 mm for the anterolateral portal and 4.4 ± 0.6 mm for the posterolateral portal (P = .18). We did not observe a significant difference in biomechanical strength (P > .05). Conclusions: There is a high rate of glenoid perforation in close proximity to the suprascapular nerve when placing anchors in the posterosuperior glenoid through an anterolateral portal. Use of the posterolateral portal results in a much lower incidence of glenoid perforation for anchors placed in the posterosuperior glenoid, but there is a higher risk of glenoid perforation for an anchor placed in the anterosuperior glenoid from the posterolateral portal. Clinical relevance: There is a higher risk of injury to the suprascapular nerve when suture anchors are placed in the posterosuperior glenoid through an anterolateral portal compared with a posterolateral portal for SLAP repair.
Article
During arthroscopic Bankart repair, penetration of suture anchors through the far cortex can compromise the initial biomechanical characteristics of anchor stability and repair integrity. This study compared the placement of suture anchors through a low anterior-inferior rotator interval portal (AI) vs a trans-subscapularis portal to evaluate the rate of anchor perforation as well as biomechanical strength. Ten matched pairs of cadaveric shoulders were randomized to an AI or a trans-subscapularis portal for placement of suture anchors at the 3 o'clock and 5:30 positions. The following measurements were obtained: (1) distance from the portal to the cephalic vein; (2) presence and length of anchor penetration through the inferior glenoid; and (3) ultimate failure strength of the anchors. The distance from the portal to the cephalic vein was significantly greater with the AI vs the trans-subscapularis portal across all specimens (29.9 vs 11.2 mm, P<.05). The rate of anchor penetration was significantly increased in the AI group vs the trans-subscapularis group at the 5:30 position (60% vs 10%, P=.014) but not at the 3 o'clock position (P=.33). Mean pullout strength of the anchors at the 5:30 position trended higher in the trans-subscapularis group, but the difference was not significant (132.8 vs 112.6 N, P=.18). The cephalic vein is closer to the trans-subscapularis portal than to the AI, but is at a safe distance. Both the rate and the degree of glenoid suture anchor penetration were lower with the trans-subscapularis portal compared with the AI at the 5:30 position. Placing anchors through the trans-subscapularis portal provides a safe alternative method, with improved positioning of the inferiormost anchor compared with the traditional AI. [Orthopedics.].
Article
We studied the incidence of postoperative glenoid rim fractures and analysed the relationships of glenoid rim fracture with osteolysis, fracture pattern, number of anchors and postoperative activity after arthroscopic Bankart repair with suture anchor fixation. Among 570 patients of the Bankart repair group, nine patients who had undergone revision arthroscopy for glenoid rim fracture after initial Bankart repair with at least two years post-revision follow-up were enrolled. Mean age was 28.8 years (range, 18-49 years), and mean follow-up was 36.4 months (range, 25-64 months). The mean time from Bankart repair to failure of initial surgery following trauma was 27.3 months (range, four to-84 months). Initial suture anchors were made of bioabsorbable composites (poly-D-L-lactic acid, PDLLA) without ceramic osteo-filler (seven cases) and metals (two cases). PDLLA without ceramic osteo-filler suture anchors were used for revision surgery. We reviewed 570 patients for relationship between osteolysis and glenoid rim fracture. Five patients including three and two with bioabsorbable and metal suture anchors, respectively, experienced glenoid rim fracture at more than two years postoperatively. Osteolysis around initial suture anchors groups showed higher glenoid rim fracture incidence compared with the control group (odd ratio =4.186 [95 % CI, 1.108-15.818]; p = 0.037). Osteolysis related to insertion of metal or PLDDA suture anchors may lead to glenoid rim fracture. Remnant metal or bioabsorbable suture anchors without ceramic composite could be a stress riser at two years postoperatively.
Article
Purpose The purpose of this study was to evaluate the accuracy of inserting a glenoid anchor at the 5:30 clockface position using a trans-subscapularis (TSS) portal versus a low anterior (LA) portal. Methods Five surgeons (T.D., J.C., C.V., D.J.O-H., J.S.T.) placed a single anchor in 20 fresh-frozen cadaveric shoulders. In each of 2 shoulders, surgeons used an LA portal to insert the anchor, whereas in 2 shoulders a TSS portal was used. Surgeons were directed to place the anchor at the 5:30 position at an angle 45° to the glenoid surface (axial plane) and passing perpendicular to the glenoid rim in the coronal plane. Shoulders were then dissected and computed tomographic (CT) scans obtained. Anchor position relative to the clockface was documented by 2 blinded assessors, as was the angle of insertion in the axial and coronal planes. Statistical significance was calculated with a Student t test for paired samples (confidence interval [CI], 95%; significance, P < .05). Results The average deviation from the 5:30 position was 48 minutes (standard deviation [SD], 31 minutes) for the LA portal (average position, 4:42 o’clock) versus 28.5 minutes (SD, 19 minutes) for the TSS group (average position, 5:02 o’clock) (P = .15). The average angle of anchor insertion in the axial plane was 67.2° (SD, 19°) for the LA portal versus 62.8° (SD, 14°) for the TSS portal (P = .49), whereas the average angle of insertion in the coronal plane was 31.3° (SD, 14°) of inferior angulation in the LA group and 14.3° (SD, 8°) of inferior angulation in the TSS group (P = .009). Of the anchors inserted, 9 of 20 (45%) showed evidence of far-cortical perforation. No difference in cortical perforation was seen between the 2 portals, with perforation more likely with anchors inserted greater than 45° in the axial plane (8 of 20) than with those inserted less than 45° (1 of 20) (P = .02). Conclusions The use of a TSS portal improves the angle of approach to the inferior glenoid rim in comparison with an LA portal, reducing the acuity of the angle of insertion in the coronal plane. Clinical Relevance The TSS portal is an option for surgeons performing arthroscopic Bankart repair using anchors low on the glenoid rim.
Article
Purpose: The purpose of this study was to compare the risk of injury to the suprascapular nerve during suture anchor placement in the glenoid when using an anterosuperior portal versus a rotator interval portal. Methods: Ten bilateral fresh human cadaveric shoulders were randomized to anchor placement through the anterosuperior portal on one shoulder and the rotator interval portal on the contralateral shoulder. Standard 3 × 14 mm suture anchors were placed in the glenoid rim (1 o'clock, 11 o'clock, and 10 o'clock positions for the right shoulder). The suprascapular nerve was dissected. When glenoid perforation occurred, the distance from the anchor tip to the suprascapular nerve, the distance from the glenoid rim to the suprascapular nerve, and the drill-hole depth at each entry site were recorded. Results: All far-posterior anchors perforated the glenoid rim when using the anterosuperior or rotator interval portal. The distance from the far-posterior anchor tip to the suprascapular nerve averaged 8 mm (range, 3.4 to 14 mm) for the anterosuperior portal and 2.1 mm (range, 0 to 5.5 mm) for the rotator interval portal (P ≤ .001). Conclusions: Using an anterosuperior or rotator interval portal results in consistent penetration of 1 o'clock and 2 o'clock posterior anchors and might place the suprascapular nerve at risk of iatrogenic injury. Based on closer proximity of the anchor tip to the suprascapular nerve, the risk of injury is significantly greater with a rotator interval portal. Clinical relevance: Using a rotator interval portal for suture anchor placement in the posterior aspect of the glenoid rim can lead to a higher likelihood of suprascapular nerve injury.
Article
Background: There have been no studies on the postoperative morphological characteristics of the restored labrum at different glenoid locations and its clinical relevance after arthroscopic Bankart repair with suture anchors. Purpose: To analyze the morphological characteristics of the restored labrum at different locations of the glenoid and their relevance to clinical outcomes as well as affecting factors and to trace the inserted suture anchors after arthroscopic Bankart repair using computed tomography arthrography (CTA). Study design: Case series; Level of evidence, 4. Methods: A total of 46 patients (mean age, 26.5 ± 6.8 years) who underwent arthroscopic Bankart repair with absorbable suture anchors were enrolled in this study. Patients underwent CTA preoperatively and 6 months postoperatively as well as functional outcome evaluation preoperatively and at the last follow-up (>24 months) with the Rowe score and visual analog scale for pain. Labral height and width were measured on conventional axial CTA images at the 3-, 4-, and 5-o'clock positions twice by 2 raters. The postoperative measurements were also compared with those of the healthy anterior labrum, acquired from the same CTA examination of 32 consecutive patients (mean age, 26.5 ± 8.5 years) with superior labral lesions in the same study period. The postoperative difference in the measurements and between clock positions, and the relationship between the measurements and the clinical factors and functional outcomes, were evaluated. In addition, the locations of all suture anchors were traced on each CTA image, and outcomes according to the locations of the most inferior suture anchors were assessed. Results: The interobserver and intraobserver reliabilities of measurements at each location were excellent (Pearson correlation coefficient = 0.773-0.988). Of the 46 patients, 2 (4.35%) had redislocations after surgery. Postoperative labral height and width were significantly increased at all locations (all P < .001) up to a level similar to the healthy anterior labrum, with significantly larger values at the inferior location compared with the superior location (all P < .05). Patients who had a greater frequency of dislocations before surgery showed a lower postoperative labral height at the 5-o'clock position (P = .012), and this correlated with postoperative instability and poor functional outcomes by the Rowe score (P = .036). In most patients (41/46; 89.1%), the tips of the lowest suture anchors perforated the far cortex, and these anchors were mostly located below the 5-o'clock position (32/41; 78.0%). However, perforation of the far cortex did not affect functional outcomes. Conclusion: Surgeons should be cautious of restoring labral height at the inferior glenoid location for successful arthroscopic Bankart repair. In addition, attention should be given to inserting the lowest suture anchor regardless of clinical significance.
Article
Background During arthroscopic Bankart repair, inferior anchor placement is critical to a successful outcome. Low anterior anchors may be placed with a standard straight guide via midglenoid portal, with a straight guide with trans-subscapularis placement, or with curved guide systems. Purpose/Hypothesis To evaluate glenoid suture anchor trajectory, position, and biomechanical performance as a function of portal location and insertion technique. It is hypothesized that a trans-subscapularis portal or curved guide will improve anchor position, decrease risk of opposite cortex breach, and confer improved biomechanical properties. Study Design Controlled laboratory study. Methods Thirty cadaveric shoulders were randomized to 1 of 3 groups: straight guide, midglenoid portal (MG); straight guide, trans-subscapularis portal (TS); and curved guide, midglenoid portal (CG). Three BioRaptor PK 2.3-mm anchors were inserted arthroscopically, with an anchor placed at 3, 5, and 7 o’clock. Specimens were dissected with any anchor perforation of the opposite cortex noted. An “en face” image was used to evaluate actual anchor position on a clockface scale. Each suture anchor underwent cyclic loading (10-60 N, 250 cycles), followed by a load-to-failure test (12.5 mm/s). Fisher exact test and mixed effects regression modeling were used to compare outcomes among groups. Results Anchor placement deviated from the desired position by 9.9° ± 11.4° in MG specimens, 11.1° ± 13.8° in TS, and 13.1° ± 14.5° in CG. After dissection, opposite cortex perforation at 5 o’clock occurred in 50% of MG anchors, 0% of TS, and 40% of CG. Of the 90 anchors tested, 17 (19%) failed during cyclic loading, with a similar failure rate across groups ( P = .816). The maximum load was significantly higher for the 3-o’clock anchors when compared with the 5-o’clock anchors, regardless of portal or guide ( P = .021). For the 5-o’clock position, there were significantly fewer “out” anchors in the TS group versus the CG or MG group ( P = .038). There was no statistically significant difference in maximum load among groups at 5 o’clock. Conclusion Accuracy in suture anchor placement during arthroscopic Bankart repair can vary depending on both portal used and desired position of anchor. The results of the current study indicate that there was no difference in ultimate load to failure among anchors inserted via a midglenoid straight guide, midglenoid curved guide, or percutaneous trans-subscapularis approach. However, midglenoid portal anchors drilled with a straight or curved guide and placed at the 5-o’clock position had significant increased risk of opposite cortex perforation compared with trans-subscapularis percutaneous insertion, with no apparent biomechanical detriment. Clinical Relevance The findings from this study will facilitate improved understanding of risks and benefits of several techniques for arthroscopic shoulder instability treatment with regard to suture anchor fixation.
Article
Arthroscopic Bankart procedures have been well described, and their results have produced a significant improvement over those of other arthroscopic capsulorraphy techniques. Nonetheless, objections to these arthroscopic Bankart techniques persist. The primary objections are the drilling of transscapular pins out the posterior scapular neck in proximity to the suprascapular nerve and the tying of sutures over the muscle belly and fascia of the infraspinatus. The arthroscopic Bankart procedure using suture anchors nullifies these objections by the fixation of sutures, placed in the detached ligament labral complex, directly to the anterior glenoid rim without transscapular drilling. The procedure was performed in 14 patients with anterior inferior instability. The instability was conformed by examination under anesthesia, and the intra-articular pathology was evaluated arthroscopically. Two or three sutures and anchors were used to reattach and retension the inferior glenohumeral ligament labral complex. The procedure requires the use of two anterior portals and intra-articular knot-tying techniques. Although the follow-up is short, there have been no complications and no recurrences of the symptoms of instability. This new approach offers distinct advantages over existing arthroscopic Bankart techniques without altering the basic principles of the procedure. Suture anchors, intially designed to facilitate traditional open Bankart procedures, can also be used arthroscopically, thus avoiding transscapular drilling and risk to posterior structures.
Article
The aims of this study were to evaluate the incidence of anchor penetration of the far cortex of the glenoid neck after arthroscopic Bankart repair and to compare the biomechanical properties of anchors in the 4- and 5:30- to 6-o'clock positions on the glenoid. Twelve (6 matched pairs) fresh-frozen human cadaveric shoulders were used to simulate arthroscopic Bankart repair in the lateral decubitus position. The most inferior anchor (5:30 to 6 o'clock) and that above it (4 o'clock) were inserted via the anteroinferior portal on the glenoid using the standard technique. After both anchor insertions, anchor perforation of the glenoid far cortex was identified. Biomechanical properties were measured to determine cyclic displacement of anchors at 100 and 500 cycles, stiffness, yield load, and ultimate failure strength. All 12 suture anchors (100%) at 5:30 to 6 o'clock penetrated throughout the far cortex, whereas only 4 anchors (33%) at 4 o'clock did so (P = .005). The mean distance the anchor tip traveled into far cortex was significantly longer at 5:30 to 6 o'clock than at 4 o'clock (6.8 ± 1.6 mm v 2.0 ± 1.6 mm, P = .001). In terms of mechanical strength, anchors at 5:30 to 6 o'clock had greater 100- and 500-cycle mean displacements than those at 4 o'clock (3.0 ± 0.5 mm v 2.5 ± 0.3 mm, P = .018 for 100 cycles; 3.5 ± 0.7 mm v 2.8 ± 0.3 mm, P = .018 for 500 cycles), although no differences in ultimate failure strength after cyclic loading were found between 2 positions (133.4 ± 40.3 and 133.7 ± 29.2 N, respectively; P = .985). For arthroscopic Bankart repair, insertion of the most inferior anchor via the anteroinferior portal with standard technique, in the lateral decubitus position, carries a high risk of perforating the inferior far cortex of the glenoid (100% in our study). This may result in mechanical weakness of the most inferior repair specifically in the early postoperative period. Perforation of the glenoid far cortex by the most inferior anchor and its mechanical weakness should be taken into consideration. Further study is needed to improve surgical technique to place the most inferior anchor in an optimal position by arthroscopy.
Article
Background The present study aimed to determine the rate of clinically significant neurovascular complications associated with the routine use of the 5 o'clock portal during arthroscopic Bankart repair. Methods Forty-eight consecutive patients underwent arthroscopic Bankart repair with the use of the 5 o'clock portal. These patients were followed at 2 weeks and 6 weeks postoperatively for subjective signs of neurovascular injury (i.e. numbness and tingling) as well as objective signs (i.e. intraoperative bleeding, radial pulse, capillary refill, sensation, motor strength, haematoma and oedema). Results Two out of 48 patients (4.2%) experienced transient neurological symptoms in an ulnar nerve distribution, which resolved by 6 weeks. There was no occurrence of clinically significant injury to the axillary nerve, axillary artery, musculocutaneous nerve, lateral cord of the brachial plexus or cephalic vein. Conclusions No clinically detectable neurovascular injuries were associated with the use of the 5 o'clock shoulder portal during Bankart repair.
Article
The objective of this study was to compare the functional assessments of arthroscopy and open repair for treating Bankart lesion in traumatic anterior shoulder instability. Fifty adult patients, aged less than 40 years, with traumatic anterior shoulder instability and the presence of an isolated Bankart lesion confirmed by diagnostic arthroscopy were included in the study. They were randomly assigned to receive open or arthroscopic treatment of an isolated Bankart lesion. In all cases of both groups, the lesion was repaired with metallic suture anchors. The primary outcomes included the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. After a mean follow-up period of 37.5 months, 42 patients were evaluated. On the DASH scale, there was a statistically significant difference favorable to the patients treated with the arthroscopic technique, but without clinical relevance. There was no difference in the assessments by University of California, Los Angeles and Rowe scales. There was no statistically significant difference regarding complications and failures, as well as range of motion, for the 2 techniques. On the basis of this study, the open and arthroscopic techniques were effective in the treatment of traumatic anterior shoulder instability. The arthroscopic technique showed a lower index of functional limitation of the upper limb, as assessed by the DASH questionnaire; this, however, was not clinically relevant.
Article
Arthroscopic treatment has evolved to become the primary surgical option in the management of anterior shoulder instability as studies show comparable outcomes between open and arthroscopic techniques. To evaluate prospectively the results of our institutional database for arthroscopic Bankart repairs at a minimum 2-year follow-up for patients with anterior instability treated with suture anchors. Case series; Level of evidence, 4. Eighty-three consecutive patients underwent arthroscopic Bankart repair with suture anchors. The mean age at the time of surgery was 33 years (range, 15-55 years). At an average follow-up of 33 months (range, 24-49 months), 73 patients (61 males, 12 females) were assessed with outcomes scores including the American Shoulder and Elbow Surgeons, L'Insalata, and visual analog scores. The rate of recurrent instability, range of motion, and risk factors for postoperative recurrence were evaluated. Thirteen patients (18%) suffered a recurrence after surgery. Seven patients (10%) had a subsequent dislocation and 6 (8%) a subluxation event or apprehension. Six of the 13 had a traumatic event that resulted in recurrent episodes of instability. Revision surgery was needed for 2 patients (3%) for instability and 2 for postoperative shoulder stiffness. On average there was no significant loss of external rotation postoperatively (average, 71 degrees pre- and postoperatively). The American Shoulder and Elbow Surgeons and L'Insalata scores improved from 75.4 to 94.9 and 66.5 to 90.9, respectively (P <.0001). The visual analog score improved from 2.4 to 0.4 (P <.001). Patient age under 25, ligamentous laxity, and the presence of a large (>250 mm(3)) Hill-Sachs lesion were associated with recurrence (P <.05). Patients under age 20 had a 37.5% recurrence rate. In the arthroscopic treatment of anterior instability, identification of risk factors for recurrence allows for appropriate patient counseling and consideration of open stabilization. In our series, patients under age 25, with ligamentous laxity, and with a large (>250 mm(3)) Hill-Sachs lesion were at the greatest risk of recurrence.
Article
The purpose of this study was to determine the effect of sectioning of the anterior part of the inferior glenohumeral ligament (a simulated Bankart lesion) on load-induced multidirectional glenohumeral motion. Nine fresh, intact cadaveric shoulders were tested on a special apparatus that constrained three rotations but allowed simultaneous measurement of anterior-posterior, superior-inferior, and medial-lateral translation. Coupled anterior-posterior and superior-posterior translations were recorded while anterior, posterior, superior, and inferior forces of fifty newtons were applied sequentially. Testing was done in three positions of humeral elevation in the scapular plane, in three positions of humeral rotation, and with an externally applied joint-compression load of twenty-two newtons. A liquid-metal strain-gauge was placed on the posterior band of the inferior glenohumeral ligament to assess concomitant posterior capsular strain during the various test conditions. All shoulders were tested intact and again after the inferior glenohumeral ligament and the labrum had been detached from the glenoid from just superior to the anterior band of the inferior glenohumeral ligament to a point just posterior to the infraglenoid tubercle. The simulated Bankart lesion resulted in selected increases in anterior translation at all positions of elevation, in posterior translation at 90 degrees of elevation, and in inferior translation at all positions of elevation. However, these increases were very small; the maximum mean increase in translation seen over-all was only 3.4 millimeters, which occurred during inferior translation at 45 degrees of elevation.(ABSTRACT TRUNCATED AT 250 WORDS)
Article
The present study describes an anterior-inferior portal for arthroscopic shoulder instrumentation at the 5 o'clock position along the glenoid rim. An anterior-inferior portal was established in 14 cadaver shoulders. The portal was created in an inside-to-outside fashion, with the humerus maximally adducted, directing the guide rod as far lateral as possible. Using the described technique, a 5 o'clock portal travels through the subscapularis and lateral to the conjoined tendon. Distance between the portal and the musculocutaneous nerve was 22.9 +/- 4.9 mm (mean +/- SD), and 24.4 +/- 5.7 mm between the portal and the axillary nerve. Previously described portals were either at, or above the 3 o'clock position, resulting in an acute, difficult angle of approach to the glenoid neck. Through a combination of proper arm positioning and rod insertion technique, the 5 o'clock portal can be created safely and is of great potential utility for arthroscopic shoulder stabilization procedures.
Article
Two-hundred eighty-two patients underwent anterior reconstruction for recurrent glenohumeral instability between 1981 and 1991. Twenty-three patients (8.2%) had a neurologic deficit after surgery. Seven had sensory disturbances only; 16 had sensorimotor neuropathies (8 having multiple deficits designated as a diffuse plexopathy and 8 having a more defined deficit in 1 or 2 cords or peripheral nerves). Complete resolution occurred in 18 of the 23 patients. Four patients had a residual deficit (1 patient was lost to follow-up). Three had persistent sensory disturbances; 1 had permanent biceps weakness. None of these patients underwent surgical exploration. Older age (P = .045) and a Bankart lesion (P = .029) were associated with a neurologic complication. At an average follow-up of 8.7 years, 252 patients responded to a questionnaire regarding shoulder outcome, including 20 of the 23 patients with nerve injuries. The difference in the median Rowe score of those with and without nerve injury was not significant (P = .072). Neurologic injuries after anterior shoulder surgery presumably arise as a result of traction. The prognosis for neurologic recovery is generally good. Neurologic injury did not interfere with the outcome of the stabilization procedure.
Article
Previous studies on arthroscopic treatment of anterior-inferior glenohumeral instability have focused on the repair of lesions of the anterior-inferior aspect of the labrum (Bankart lesions) and have demonstrated failure rates of as high as 50 percent. The current investigation supports the concept that anterior-inferior instability is associated with multiple lesions and that success rates can be increased by treating all of the lesions at the time of the operation. We present the results of arthroscopic treatment of anterior-inferior gleno-humeral instability after a minimum duration of followup of two years. The study group consisted of fifty-three patients who had a mean age of thirty-two years (range, fifteen to fifty-eight years) at the time of the operation. There were forty-four male and nine female patients. The mean interval from the time of the operation to the final follow-up evaluation was thirty-three months (range, twenty-six to sixty-three months). The scores on the American Shoulder and Elbow Surgeons (ASES) Shoulder Index and the rating systems of Constant and Murley, Rowe et al., and the University of California at Los Angeles (UCLA) were recorded preoperatively and at the time of the final follow-up. Preoperatively, none of the patients had an overall rating of good or excellent according to the system of Rowe et al.; however, 92 percent (forty-nine) of the fifty-three patients had a rating of good or excellent at the time of the final follow-up. The mean score improved from 45.5 points to 91.7 points on the ASES Shoulder Index, from 56.4 points to 91.8 points with the system of Constant and Murley, from 11.3 points to 91.9 points with the system of Rowe et al., and from 17.6 points to 32.0 points according to the UCLA Shoulder Score (p = 0.001 for all comparisons). The mean passive external rotation with the shoulder in 90 degrees of abduction measured 88.2 degrees. Thirty-four of thirty-eight patients returned to their desired level of sports activity following the operation. Four patients who had persistent instability were considered to have had a failure of the index operation, and one of them had a second operative procedure. The results of the present study suggest that our technique of arthroscopic treatment of anterior-inferior glenohumeral instability is better than previous arthroscopic techniques and is equivalent to open repair. We believe that the improved rate of success demonstrated in the present study was the result of repair not only of the anterior-inferior (Bankart) lesion but also (where necessary) of inferior and superior labral tears. Additionally, soft-tissue tension within the capsule and ligaments was corrected with use of a suture technique but was supplemented by laser thermal capsulorrhaphy in forty-eight of the fifty-three shoulders. Rotator interval repair was considered a critical factor in fourteen of the fifty-three shoulders.
Article
The purpose of this study was to compare the results of arthroscopic and open repair of isolated Bankart lesions of the shoulder using metallic suture anchors. Prospective randomized clinical study. Sixty patients with traumatic anterior shoulder instability underwent a surgical repair of an isolated Bankart lesion. The patients were divided into 2 groups of 30 patients each. In group 1, an arthroscopic repair was performed, and in group 2, an open procedure was performed. The groups were homogeneous for gender, age, dominance, number of dislocations, time elapsed between first dislocation and surgery, and pathologic findings. In all cases of both groups, the lesion was repaired using metallic suture anchors carrying nonabsorbable braided sutures. Postoperative rehabilitation was the same for the 2 groups. Two years' follow-up evaluation included Constant and Rowe shoulder scores. Statistical analysis of data was performed using an unpaired t test (significance for P <.05). No recurrence of dislocation of the involved shoulder has been reported in either group. Follow-up Constant and Rowe scores of the 2 groups were not significantly different. The only significant difference seen between the 2 groups was for range of motion evaluation with the Constant score. The mean value for group 1 (39.6 +/- 0.8) was significantly greater (P =.017) than that for group 2 (37.8 +/- 2.0). Arthroscopic repair with suture anchors is an effective surgical technique for the treatment of an isolated Bankart lesion. Open repair does not offer a significantly better 2-year result in terms of stability, and furthermore, can negatively affect the recovery of full range of motion of the shoulder. Level I.
Article
The higher failure rates reported with arthroscopic stabilization of traumatic, recurrent anterior shoulder instability compared with open stabilization remain a concern. The purpose of this study was to evaluate the outcomes of arthroscopic Bankart repairs with the use of suture anchors and to identify risk factors related to postoperative recurrence of shoulder instability. Ninety-one consecutive patients underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. The mean age (and standard deviation) at the time of surgery was 26.4 +/- 5.4 years. Seventy-one patients were male. Seventy-nine patients were involved in sports (forty, in high-risk sports). Capsulolabral reattachment and capsule retensioning was performed with use of absorbable suture anchors (mean, 4.3 anchors; range, two to seven anchors). All patients were prospectively followed, and, at the time of the last review, the patients were examined and assessed functionally by independent observers. At a mean follow-up of thirty-six months, fourteen patients (15.3%) experienced recurrent instability: six sustained a frank dislocation and eight reported a subluxation. The mean delay to recurrence was 17.6 months. The risk of postoperative recurrence was significantly related to the presence of a bone defect, either on the glenoid side (a glenoid compression-fracture; p = 0.01) or on the humeral side (a large Hill-Sachs lesion; p = 0.05). By contrast, a glenoid separation-fracture was not associated with postoperative recurrent dislocation or subluxation. Recurrence of instability was significantly higher in patients with inferior shoulder hyperlaxity (p = 0.03) and/or anterior shoulder hyperlaxity (p = 0.01). On multivariate analysis, the presence of glenoid bone loss and inferior hyperlaxity led to a 75% recurrence rate (p < 0.001). Lastly, the number of suture-anchors was critical: patients who had three anchors or fewer were at higher risk for recurrent instability (p = 0.03). In the treatment of traumatic recurrent anterior shoulder instability, patients with bone loss or with shoulder hyperlaxity are at risk for recurrent instability after arthroscopic Bankart repair. At least four anchor points should be used to obtain secure shoulder stabilization.
Article
The purpose of this anatomic cadaveric study was to determine with trocars in situ the relationships of 12 shoulder arthroscopic portals frequently used with the adjacent musculotendinous and neurovascular structures. Twelve shoulders of embalmed cadavers installed in a beach-chair position were dissected. Twelve different portals were established by using their authors' description: posterior "soft point," central posterior, anterior central, anterior inferior, anterior superior, 5 o'clock portal, Neviaser, superolateral, transrotator cuff approach, Port of Wilmington, anterolateral, and posterolateral. Six of these portals were placed on each shoulder so that each portal was studied 6 times. Dissections were conduced with trocars in situ to take into account their volume. The distance to the adjacent relevant neurovascular structures at risk (axillar and suprascapular nerves, axillar and suprascapular arteries, and cephalic vein) were measured, arm at side, by using a calliper. Musculotendinous structures crossed by portals were noticed. The cephalic vein was injured twice by anterior portals. The 5 o'clock portal is at most risk of neurovascular injury. It is located at mean distances to the axillar artery and nerve of 13 and 15 mm, respectively. Other anterior, posterior, superior, and lateral portals are safe with mean distances higher than 20 mm. No musculotendinous rupture nor large injury occurred. The present study shows that the trocars placement of the studied portals did not create, except for the cephalic vein, any lesion of the neurovascular adjacent structures. This study suggests, except for the 5 o'clock portal, the safety of the shoulder arthroscopic portals tested regarding to the neurovascular adjacent structures.
Article
The purpose of this study was to assess, using a technique that minimally distorts the normal anatomy, the risk of injury when establishing a 5 o'clock shoulder portal in the lateral decubitus versus beach-chair position. The anteroinferior portal was simulated with Kirschner wires (K-w) drilled orthogonally at the 5 o'clock position in 13 fresh frozen human cadaveric shoulders. The neighboring neurovascular structures were identified through an anteroinferior window made in the inferior glenohumeral ligament. Their relations to the K-w and surrounding structures were recorded in both positions. The median distance from the musculocutaneous nerve to the K-w was shorter in the lateral decubitus position than in the beach chair position (13.16 mm v 20.49 mm, P = .011). The cephalic vein was closer to the portal in the beach-chair position than in the lateral decubitus position (median 8.48 mm v 9.93 mm, P = .039). The axillary nerve was closer to the K-w in the lateral decubitus position than in the beach-chair position (median 21.15 mm v 25.54 mm, P = .03). No differences in the distances from the K-w to the subscapular and anterior circumflex arteries were found when comparing both positions. The mean percentage of subscapular muscle height from its superior border to the K-w was 53.03%. This study showed the risk of injury establishing a transubscapular portal in either position. The musculocutaneous nerve and the cephalic vein are the most prone to injury. In general, the beach-chair position proved to be safer. Inserting anchor devices orthogonally would permit stronger fixation but presents the risk of damaging neurovascular structures. This study focused on showing the neurovascular risk of performing full orthogonal insertion. Considering the good results reported with the usual superior-anterior portals, we do not recommend performing a transubscapular portal in routine shoulder arthroscopy.