Open Bankart Repair: Where do We Stand Now?

The operative treatment for recurrent traumatic anterior shoulder dislocation is classified as an anatomical or non-anatomical technique. The anatomical technique was first described for more than 80 years ago by Dr. Arthur. S. B. Bankart. [Table: see text] Up to date, Bankart repair still is the most common procedure performed to treat recurrent anterior dislocation of the shoulder joint with Bankart lesion, the anterior-inferior labral disruption, namely as the most common pathology observed in 85% of those patients.2 At the earlier year, many orthopedic surgeons favored the open Bankart procedure for its reliable long term follow up result. Hence, open Bankart has been historically considered the gold standard in the treatment of shoulder instability. Open Bankart repair was previously a standard care, resulting in recurrence rates below 10%.3 Advocates of open Bankart surgery argue that a more anatomic and secure repair is reliably accomplished. However, arthroscopic shoulder stabilization methods have also evolved significantly during the past 25 years. Initially, there was an early disappointment for the high failure rates for arthroscopic Bankart repair as great as 49% for its trans-glenoid suturing and 23% for its bio-absorbable tack fixation.4 However, suture anchor came or should I say “save the day” and reduce the failure rates to 8 – 11% combined with capsular plication.5 United States’s data showed that arthroscopic Bankart repairs are increasingly used, from 71.2% of all cases in 2004 to 89% in 2009.6 Given the ceiling effect of a surgical learning curve in the last decade, the recurrence and failures rate should have been substantially decreased. These numbers have led to the suggestion that, could it be that arthroscopic Bankart repair with suture anchors is our ”blue ribbon” in this “competition”? Should we say ”abandon ship” now to open Bankart repair? A recent meta-analysis of open versus arthroscopic shoulder stabilization comparing 2 recent decades (the past 20 years) demonstrated there was no significant difference in improvements achieved for clinical outcomes and external rotation deficits.7 The recurrence rate for open Bankart surgery remained resolutely consistent at 10.7% (at the past 20 years) and 10.6% (at the past 10 years). The glory of arthroscopic surgery that has been taught for generations in orthopedic surgery is the ability to recon the additional intra-articular pathology with lower surgical morbidity, improved cosmesis and decreased pain. However, the earlier one can be mostly encountered by the advanced imaging system used these days. Hence, I would like to say, open Bankart surgery is considered not a history lesson and may be worthy to revisit. References Bankart ASB. The pathology and treatment of recurrent dislocation of the shoulder joint. British Journal of Surgery 1938; 26: 7. DOI: 10.1002/bjs.18002610104. Rowe CR, Patel D and Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am 1978; 60: 1-16. 1978/01/01. Rowe CR, Zarins B and Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am 1984; 66: 159-168. 1984/02/01. Freedman KB, Smith AP, Romeo AA, et al. Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for Recurrent Anterior instability of the shoulder: a meta-analysis. Am J Sports Med 2004; 32: 1520-1527. 2004/08/18. DOI: 10.1177/0363546504265188. Brophy RH and Marx RG. The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Arthroscopy 2009; 25: 298-304. 2009/02/28. DOI: 10.1016/j.arthro.2008.12.007. Zhang AL, Montgomery SR, Ngo SS, et al. Arthroscopic versus open shoulder stabilization: current practice patterns in the United States. Arthroscopy 2014; 30: 436-443. 2014/02/25. DOI: 10.1016/j.arthro.2013.12.013. Hohmann E, Tetsworth K and Glatt V. Open versus arthroscopic surgical treatment for anterior shoulder dislocation: a comparative systematic review and meta-analysis over the past 20 years. J Shoulder Elbow Surg 2017; 26: 1873-1880. 2017/07/10. DOI: 10.1016/j.jse.2017.04.009.

Recurrent anterior shoulder dislocation with glenoid fracture managed by modified Boytchev procedure: a rare case report

<p class="abstract">Surgical procedures for recurrent anterior dislocation of the shoulder include using capsuloligamentous or bone blocks to create barriers and active interventions using muscle actions. Fracture of glenoid acts as a barrier for bone block procedures. Boytchev procedure, though outmoded, yet acts as simple and effective procedure in this condition. Here we report a 44 year old male with recurrent anterior dislocation with glenoid fracture treated by Boytchev procedure. The patient is on regular follow up since 3 years with no episode of shoulder dislocation till now with full range of movements. To conclude, Boytchev procedure is technically simple and effective method in patients with recurrent anterior shoulder dislocation with fracture of glenoid.</p>

In Which Arm Position Is a Hill-Sachs Lesion Created?

Background: It has been believed that a Hill-Sachs lesion (HSL) is created with the arm in abduction and external rotation at the time of dislocation. However, no studies have clarified the arm position in which an HSL is created. Purpose: To determine the arm position in which an HSL is created. Study Design: Descriptive laboratory study. Methods: The computed tomography images of 100 shoulders of 100 patients (72 males and 28 females; mean age, 30 years old) with recurrent anterior dislocation of the shoulder were investigated using an image analyzing software. Three-dimensional surface bone models of the scapula and humerus were created separately. The humerus was moved so that the HSL perfectly fit the anterior rim of the glenoid. This arm position was recorded 3-dimensionally. Results: Considering the scapulohumeral rhythm, the average arm position in which the HSL and the anterior glenoid rim best fit was 74° of abduction, 27° of external rotation, and 3° of horizontal flexion relative to the trunk. Conclusion: The arm position when an HSL and the anterior glenoid rim best fit is 74° of abduction, 27° of external rotation, and 3° of horizontal flexion, which seems to be the arm position when the HSL has been created. This result suggests 2 possibilities: dislocation occurred in this midrange position or HSL was not created at the time of dislocation but later in the mid–range of motion. However, as we have no information on the arm position at the time of dislocation, we cannot conclude which of these possibilities is true in our study. Clinical Relevance: This study gives us a better understanding of the timing of HSL occurrence. Shoulder dislocation may occur at the end range of motion or in the mid–range of motion, but an HSL is created in the mid–range of motion.