Open vs. Arthroscopic Bankart Repairs

Abstract & Commentary

Synopsis: This is a prospective, comparative study of open and arthroscopic shoulder stabilization procedures for patients with traumatic, anterior instability. Both groups were reported to show comparable, successful results. There was a higher recurrence rate in the arthroscopic group, and there was more restriction of abduction/external rotation in the open group.

Source: Karlsson J, et al. Comparison of open and arthroscopic stabilization for recurrent shoulder dislocation in patients with a bankart lesion. Am J Sports Med. 2001;29(5): 538-542.

This is a prospective, comparative study of 117 patients with traumatic, anterior shoulder instability. All patients had recurrent instability. Any patient who did not have a Bankart lesion was excluded from the study. Three different surgeons performed procedures, and the patients decided upon open vs. arthroscopic technique in most cases. In some cases, the surgeon chose the type of surgery. Arthroscopic surgery was performed with a SureTac absorbable tack. Some arthroscopic cases were performed with an "extraarticular" procedure and some were performed with an "intraarticular" procedure. Four patients from the arthroscopic group were excluded from the study because they were converted to open procedures due to "technical difficulties." The open procedures were performed with TAG suture anchors and "a 1 cm capsular shift," with the arm in 20° of external rotation.

Results were recorded at a mean of 28 months for the arthroscopic group (66 patients) and 36 months for the open group (53 patients). Nine patients in the arthroscopic group (9/60) were regarded as failures, including 7 redislocators (12%) and 2 subluxators (3%). Five patients in the open group (5/48) were regarded as failures, including 2 redislocators (4%) and 3 subluxators (6%). Additionally, an independent observer performed outcome measures. Patients who were reoperated for recurrent instability or capsular contractures were excluded from the outcome assessment, including 4 patients in the arthroscopic group (4 recurrent instabilities), and 3 patients in the open group (1 recurrent instability, 2 capsular contractures). There were no statistically significant differences in the outcome scores for the patients who did not have revision surgery.

Comment by Stephen B. Gunther, MD

Open Bankart reconstruction has been the gold standard for stabilization surgery for traumatic, anterior instability for many years. Rowe and associates published results on a large series of these patients in 1978 with a 3.5% recurrence rate.1 The surgical protocol involved a capsulolabral repair to the glenoid using punch holes on the osteocartilaginous rim. Subsequent variations of this technique that have not addressed the capsular laxity from plastic deformation have shown higher failure rates. Also, repairs to the glenoid neck instead of the osteocartilaginous rim have shown higher failure rates since they do not reproduce anatomical congruence and conformity. Many different types of arthroscopic repairs have been developed over the past 10 years, and many of these procedures have failed at unacceptably high rates because of the 2 factors mentioned above. Recent advances in arthroscopic suture anchors, suture passing devices, and surgeon skills have allowed experienced shoulder surgeons to perform this Bankart surgery with better results that more closely approximate Dr. Carter Rowe’s results from 1978.

This article compares open and arthroscopic results performed by 3 different surgeons with varying techniques. The results are comparable when considering recurrent subluxators and dislocators together (15% arthroscopic, 10% open), but there is a significant difference between the groups when considering isolated redislocations (12% arthroscopic, 4% open). There was also a significant difference with respect to ROM in AB/ER with an average of 80° in the open group and 90° in the arthroscopic group. This is most likely directly related to the capsular shift in the open group. The outcome measures were similar in both groups. However, the failed surgical cases were excluded from the outcome results. Early failures consisted of a broken implant, an infection, a transient ulnar nerve palsy, and several cases of loss of motion.

This comparative study raises several important questions about Bankart surgery. What is the current gold standard technique for Bankart repair? How do we measure success of this surgery? Which results do patients value the most? My opinion is that both arthroscopic and open Bankart surgeries are indicated in specific patient populations. Arthroscopic repairs tend to cause less loss of motion, and open surgery tends to have a slightly lower redislocation rate. The overhead athlete may have different needs and expectations than a rock climber or hockey player. The surgeon should discuss these expectations with each individual patient and should be honest with the surgeon’s experience level with this type of surgery.

Reference

1. Rowe CR, et al. The bankart procedure: A long-term end result study. J Bone Joint Surg Am. 1978;60:1-16.

Dr. Gunther, Assistant Professor of Clinical Orthopaedic Surgery, UCSF Department of Orthopaedic Surgery, San Francisco, is Associate Editor of Sports Medicine Reports.