Treatment of Shoulder Instability - Arthroscopic Bankart Repair

Martin Bouliane, M.D., FRCSC
Assistant Professor, University of Alberta
Edmonton, AB

Arthroscopic Bankart procedure remains one of the most commonly performed shoulder operations worldwide. It remains the first line of treatment for anterior glenohumeral instability, and while it is not indicated in all cases of anterior shoulder instability, it can be used for those patients with an appropriate history, physical examination, and radiographic assessment.

 

Arthroscopic Bankart repair is generally indicated in patients with a history of recurrent unidirectional anterior traumatic instability who have failed a non-operative program emphasizing kinetic chain rehabilitation. A history of closed reduction in the emergency department is diagnostic especially if dislocation X-rays are available for review. With an increasing number of recurrences, symptoms of instability below shoulder level (so called "mid-range" symptoms), instability while sleeping, or instability in seizure patients it becomes increasingly important to rule out larger bone lesions not readily treated by an arthroscopic repair. These are historical "red flags" and should serve as a warning that an arthroscopic Bankart repair may not suffice. Physical examination should focus on range of motion, rotator cuff and neurologic assessment. Instability testing includes the apprehension and relocation test, with evaluation of shoulder hypermobility (ER >85°) or generalized ligamentous laxity, as well as assessing if multidirectional instability is present.

A series of X-rays is necessary to evaluate bone loss on both the humeral and glenoid sides. A standard series includes at least a True Glenohumeral AP, West Point Axillary, and Stryker Notch view. While small bone lesions can still be missed, the vast majority of large bone lesions will be seen. Larger bone lesions require ancillary imaging such as a CT or MRI scan for further assessment. Patients with glenoid bone loss greater than 20-25% are less suited for an arthroscopic repair, especially in cases of contact athletes. An ALPSA (Anterior Labrum Periosteal Sleeve Avulsion) lesion seen on an MRI also carries a less favourable outcome with an arthroscopic repair3.

The Instability Severity Index Score (ISIS) is a ten-point score that has been proposed as a prognostic tool for arthroscopic Bankart repair1. Age, sport, hyperlaxity and glenohumeral bone loss are the variables felt to be prognostically important. The radiographic portion represents four of the ten points, and is based on a True Glenohumeral AP in external rotation. Unfortunately, we were unable to validate the radiographic portion, demonstrating only moderate intra-rater and inter-rater reliability6. We therefore recommend caution making surgical decisions based solely on this view, and suggest ancillary three-dimensional imaging to assist in surgical decision-making when a larger bone lesion is suspected. Further, in our series of 109 patients who underwent arthroscopic Bankart repair and were prospectively evaluated, we could find no correlation between increasing ISIS score and failure of an arthroscopic repair at two years postoperatively. Glenoid bone loss, however, has been correlated with failure of arthroscopic repair by several authors especially in contact athletes1-4. While the ISIS score may be a useful guide, it should not be the only decision aid. In a recent systematic review, younger (3.

An arthroscopic Bankart repair carries little risk of significant complication such as nerve injury, infection, or significant recalcitrant stiffness. The shoulder is not altered anatomically, and future surgery is essentially uncomplicated by any surgical alterations and scarring. The biggest risk of this procedure appears to be ongoing instability that varies in the current literature from 3.4 to 35%3. In our series of 109 cases from March 2008 to July 2010, our failure rate was 5.5% at two years. While recurrence rates seem to be lower with a Latarjet (2.9%), the overall complication rate is quite high5. Based on a recent systematic review, a Bristow-Latarjet procedure carries a 30% overall complication rate with 7% undergoing repeat unplanned surgery. Complications from this procedure include neurovascular injury, infection, haematoma, and nonunion of the transferred coracoid. External rotation loss following an open Latarjet is 11.7° and 16° with an arthroscopic Latarjet5. Many of these complications are arguably worse than a recurrent dislocation.

My current practice in most instability cases is to refrain from additional three-dimensional imaging unless it is felt necessary based on identification of afore-mentioned "red flags" on history, physical exam, and plain X-rays. In straightforward cases with minimal bone loss, an arthroscopic Bankart repair is an appropriate first line of treatment. However, it is also my practice to explain and obtain consent for an open repair should it be necessary for unusual situations such as capsular tears (Humeral Avulsion of Glenohumeral Ligaments or HAGL lesion), or situations where insufficient labral tissue is present to afford a robust repair. In the latter case, as well as revision surgery, a Latarjet would be my procedure of choice.

References

  1. Balg F., Boileau P. The instability Severity Index Score. A simple pre-operative score to select patients for an arthroscopic or open shoulder staibilization. J Bone Joint Surg AM. 2009;91:2537-42.
  2. Burkhart S.S., De Beer J.F. Traumatic glenohumeral bone defectsand their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pair glenoid and the engaging Hill-sachs lesion. Arthroscopy. 2000;16:677-94.
  3. Randelli P., Ragone V., Carminati S., Cabittza P. Risk factors for recurrence after Bankart repair: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2012;20:2129-2138.
  4. Ahmed I., Ashton F., Robinson C. Arthroscopic Bankart Repair and Capsular Shift for Recurrent Anterior Shoulder Instability: Functional Outcomes and Identification of Risk Factors for Recurrence. J Bone Joint Surg Am. 2012;94:1308-15.
  5. Griesser M., Harris J., McCoy B., Hussain W., Jones M., Bishop J., Miniaci T. Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review. J Shoulder Elbow Surg 2013;22:286-292.
  6. Bouliane M., Chan H., Kemp K., Glasgow R., Beaupre L., Lambert, Sheps D. The intra and inter-rater Reliability of Plain Radiographs for Hill-Sachs and Bony Glenoid Lesions: Evaluation of the Radiographic Portion of the Instability Severity Index Score. Br J Shoulder Elbow Article first published online: 8 SEP 2012I DOI: 10.1111/j.1758-5740.2012.00208.

 

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