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Editorial Commentary: Augmented Bankart Could Be the Right Option for Subcritical Bone Loss

      Abstract

      The suitable treatment for recurrent anterior shoulder instability with subcritical glenoid bone loss remains controversial. Although the Latarjet procedure is one of the most successful surgery for shoulder instability, it has been associated with potential complications in my patients with limited bone loss and poor soft-tissue conditions, which motivated me to further investigate Bankart augmentation techniques. A myriad of them have been devised and proposed for this specific group of patients; however, there are no sufficient clinical data reported in the literature to support one of them particularly or clarify in which situation they should be used. Further comparative and prospective studies are therefore needed to build an evidence-based decision tree to help us treating our patients and better match their expectations. That said, current literature and my experience have resulted in a shift in my treatment paradigm undertaken 3 years ago to augmented Bankart in case of subcritical glenoid bone loss.
      I started my career as a shoulder surgeon doing a fellowship with Gilles Walch in 2007. During this training, Dr. Walch taught me the “best French surgery ever”: The Latarjet procedure. The latter is an exception in the shoulder field, being among the few surgeries that has almost never failed since more than 75 years. Once back home, I began to propose such stabilization to my patients in a routine manner, with excellent clinical outcomes.
      • Cunningham G.
      • Benchouk S.
      • Kherad O.
      • Lädermann A.
      Comparison of arthroscopic and open Latarjet with a learning curve analysis.
      ,
      • Lädermann A.
      • Lubbeke A.
      • Stern R.
      • Cunningham G.
      • Bellotti V.
      • Gazielly D.F.
      Risk factors for dislocation arthropathy after Latarjet procedure: A long-term study.
      Nonetheless, this surgery is technically challenging and prone to recurrences of instability or other complications,
      • Lädermann A.
      • Denard P.J.
      • Arrigoni P.
      • Narbona P.
      • Burkhart S.S.
      • Barth J.
      Level of the subscapularis split during arthroscopic latarjet.
      • Lädermann A.
      • Denard P.J.
      • Burkhart S.S.
      Injury of the suprascapular nerve during latarjet procedure: An anatomic study.
      • Lädermann A.
      • Denard P.J.
      • Tirefort J.
      • et al.
      Does surgery for instability of the shoulder truly stabilize the glenohumeral joint? A prospective comparative cohort study.
      especially in my patients with limited glenoid bone loss and poor soft-tissue conditions (e.g., hyperlaxity or inherent capsule deficiency). Since my goal is not to reproduce their original anatomy (that previously failed), I consequently devised for this specific type of patients a new Bankart augmentation technique involving the long head of the biceps.
      • Collin P.
      • Lädermann A.
      Dynamic anterior stabilization using the long head of the biceps for anteroinferior glenohumeral instability.
      Currently, a myriad of Bankart augmentation methods exists, including capsular shift,
      • Ahmed I.
      • Ashton F.
      • Robinson C.M.
      Arthroscopic Bankart repair and capsular shift for recurrent anterior shoulder instability: Functional outcomes and identification of risk factors for recurrence.
      remplissage,
      • Gouveia K.
      • Abidi S.K.
      • Shamshoon S.
      • et al.
      Arthroscopic Bankart repair with remplissage in comparison to bone block augmentation for anterior shoulder instability with bipolar bone loss: A systematic review.
      ,
      • Lee Y.J.
      • Kim C.
      • Kim S.J.
      • Yoon T.H.
      • Cho J.Y.
      • Chun Y.M.
      Does an "off-track" Hill-Sachs lesion that is misclassified as "non-engaging" affect outcomes from Bankart repair alone compared with Bankart repair combined with remplissage?.
      dynamic anterior stabilization,
      • Collin P.
      • Lädermann A.
      Dynamic anterior stabilization using the long head of the biceps for anteroinferior glenohumeral instability.
      ,
      • Mehl J.
      • Otto A.
      • Imhoff F.B.
      • et al.
      Dynamic anterior shoulder stabilization with the long head of the biceps tendon: A biomechanical study.
      closing rotator interval,
      • Chiang E.R.
      • Wang J.P.
      • Wang S.T.
      • Ma H.L.
      • Liu C.L.
      • Chen T.H.
      Arthroscopic posteroinferior capsular plication and rotator interval closure after Bankart repair in patients with traumatic anterior glenohumeral instability—A minimum follow-up of 5 years.
      ,
      • Kim S.H.
      • Ha K.I.
      • Kim Y.M.
      Arthroscopic revision Bankart repair: A prospective outcome study.
      a split subscapularis tendon flap,
      • Denard P.J.
      • Narbona P.
      • Lädermann A.
      • Burkhart S.S.
      Bankart augmentation for capsulolabral deficiency using a split subscapularis tendon flap.
      a reconstruction of the inferior glenohumeral ligament,
      • Arenas-Miquelez A.
      • Karargyris O.
      • Zumstein M.
      All-arthroscopic, 270 degrees reconstruction of the inferior glenohumeral ligament with palmaris longus autograft.
      etc. All these different techniques have several pros and cons, making it difficult to decide which one to use in clinical practice. It is furthermore essential to consider patients’ lifestyles in the decision making to better match their expectations in terms of return to sport or daily physical activities. We are therefore left to grapple with a dilemma: which one for which situation? Do they all have a place in a decision tree?
      In their article entitled “Arthroscopic Bankart Repair With Remplissage in Comparison to Bone Block Augmentation for Anterior Shoulder Instability With Subcritical Bone Loss: A Systematic Review,”
      • Gouveia K.
      • Abidi S.K.
      • Shamshoon S.
      • et al.
      Arthroscopic Bankart repair with remplissage in comparison to bone block augmentation for anterior shoulder instability with bipolar bone loss: A systematic review.
      Gouveia, Abidi, Shamshoon, Gohal, Madden, Degen, Leroux, Alolabi, and Khan found that both Bankart with remplissage and Latarjet are effective treatment options. Their findings consolidate my shift in treatment paradigm undertaken 3 years ago to augmented Bankart in case of subcritical glenoid bone loss. As expected, the main limitations of their systematic review stem from the quality and quantity of evidence available on the topic. Gouveia et al. inspire a call to action. Clinical and surgical observations must therefore continue to spur further high-level prospective and comparative researches. Otherwise, adequate indications for these various stabilization techniques will remain obscure.

      Supplementary Data

      References

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