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Bankart Repair With Subscapularis Augmentation in Athletes With Shoulder Hyperlaxity

Published:February 10, 2021DOI:https://doi.org/10.1016/j.arthro.2021.01.062

      Purpose

      The purpose of this study was to demonstrate that arthroscopic Bankart repair with associated arthroscopic subscapularis augmentation (ASA) could be a valid surgical option in the treatment of anterior shoulder instability, in collision and contact sports athletes, affected by shoulder hyperlaxity.

      Methods

      In total, 591 arthroscopic Bankart repairs plus ASA were performed in 6 shoulder centers from 2009 to 2017. Inclusion criteria were the following: collision and contact sports activities, recurrent anterior instability associated with hyperlaxity and glenoid bone loss (GBL) < 15%. Exclusion criteria were GBL > 15%, voluntary instability, multidirectional instability, pre-existing osteoarthritis and throwing athletes. The minimum follow-up was 24 months. Hyperlaxity was clinically evaluated according to Neer and Coudane-Walch tests. Before surgery, all patients underwent magnetic resonance imaging and computed tomography scanning. Pico area method was used to assess the percentage of GBL. Patients were operated on by 6 surgeons, and their functional outcomes were evaluated by 2 independent observers. The Western Ontario Shoulder Instability Index (WOSI), Rowe, American Shoulder and Elbow Surgeons (ASES) scores were used to assess results.

      Results

      Overall, 397 patients with evidence of shoulder hyperlaxity (positive sulcus sign in ER1 position and Coudane-Walch test > 85°) met all inclusion criteria. The mean WOSI score was 321; the mean Rowe score rose from 68.5 to 92.5 (P = .037), and the ASES score rose from 71.5 to 97.4 (P = .041). Seven patients (1.6%) had atraumatic redislocation, and 9 patients (2.2%) had post-traumatic redislocation. At final follow-up the mean functional deficit of external rotation was 15° with the arm in adduction (ER1 position) and 10° in abduction (ER2 position).

      Conclusions

      The Bankart repair plus ASA has been demonstrated to be safe and effective for restoring joint stability in patients practicing collision and contact sports or affected by chronic anterior shoulder instability associated with GBL (<15%) and hyperlaxity, without compromising external rotation.

      Level of Evidence

      Level IV, case series.
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      References

        • Abouali J.A.K.
        • Hatzantoni K.
        • Holtby R.
        • Veillette C.
        • Theodoropoulos J.
        Revision arthroscopic Bankart repair.
        Arthroscopy. 2013; 29: 1572-1578
        • Harris J.D.
        • Gupta A.K.
        • Mall N.A.
        • et al.
        Long-term outcomes after Bankart shoulder stabilization.
        Arthroscopy. 2013; 29: 920-933
        • Hobby J.
        • Griffin D.
        • Dunbar M.
        • Boileau P.
        Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations.
        J Bone Joint Surg Br. 2007; 89: 1188-1196
        • Zimmermann S.M.
        • Scheyerer M.J.
        • Farshad M.
        • Catanzaro S.
        • Rahm S.
        • Gerber C.
        Long-term restoration of anterior shoulder stability: A retrospective analysis of arthroscopic Bankart repair versus open Latarjet procedure.
        J Bone Joint Surg Am. 2016; 98: 1954-1961
        • Randelli P.
        • Ragone V.
        • Carminati S.
        • Cabiza P.
        Risk factors for recurrence after Bankart repair. A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 2129-2138
        • Boileau P.
        • Vilialba M.
        • Héry J.V.
        • Balq F.
        • Ahrens P.
        • Neyton L.
        Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.
        J Bone Joint Surg Am. 2006; 88: 1755-1763
        • Shah A.S.
        • Karadsheh M.S.
        • Sekiya J.K.
        Failure of operative treatment for glenohumeral instability: Etiology and management.
        Arthroscopy. 2011; 27: 681-694
        • Wolf E.M.
        • Arianjam A.
        Hill-Sachs remplissage, an arthroscopic solution for the engaging Hill-Sachs lesion: 2-to 10-year follow-up and incidence of recurrence.
        J Shoulder Elbow Surg. 2014; 23: 814-820
        • Longo U.G.
        • Loppini M.
        • Rizzello G.
        • et al.
        Remplissage, humeral osteochondral grafts, Weber osteotomy, and shoulder arthroplasty for the management of humeral bone defects in shoulder instability: Systematic review and quantitative synthesis of the literature.
        Arthroscopy. 2014; 30: 1650-1666
        • Yang J.S.
        • Mehran N.
        • Mazzocca A.D.
        • Pearl M.L.
        • Chen V.W.
        • Arciero R.A.
        Remplissage versus modified Latarjet for off-track Hill-Sachs lesions with subcritical glenoid bone loss.
        Am J Sports Med. 2018; 46: 1885-1891
        • Bastard C.
        • Herisson O.
        • Gaillard J.
        • Nourissat G.
        Impact of Remplissage on global shoulder outcome: A long-term comparative study.
        Arthroscopy. 2019; 35: 1362-1367
        • Lafosse L.
        • Lejeune E.
        • Bouchard A.
        • Kakuda C.
        • Gobezie R.
        • Kochhar T.
        The arthroscopic Latarjet procedure for the treatment of anterior shoulder instability.
        Arthroscopy. 2007; 23: 1242.e1-1242.e5
        • Griesser M.J.
        • Harris J.D.
        • McCoy B.W.
        • et al.
        Complications and re-operations after Bristow-Latarjet shoulder stabilization: A systematic review.
        J Shoulder Elbow Surg. 2013; 22: 286-292
        • Randelli P.
        • Fossati C.
        • Stoppani C.
        • Evola F.R.
        • De Girolamo L.
        Open Latarjet versus arthroscopic Latarjet: Clinical results and cost analysis.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 526-532
        • Taverna E.
        • D’Ambrosi R.
        • Perfetti C.
        • Garavaglia G.
        Arthroscopic bone graft procedure for anterior inferior glenohumeral instability.
        Arthrosc Tech. 2014; 3: e653-e660
        • Pauzemberg L.
        • Dyrna F.
        • Obopilwe E.
        • et al.
        Biomechanical evaluation of glenoid reconstruction with an implant-free J-bone graft for anterior glenoid bone loss.
        Am J Sports Med. 2017; 45: 2849-2857
        • Maiotti M.
        • Massoni C.
        Arthroscopic augmentation with subscapularis tendon in anterior shoulder instability with capsulolabral deficiency.
        Arthros Tech. 2013; 2: e303-e310
        • Maiotti M.
        • Russo R.
        • Zanini A.
        • Schroter S.
        • Massoni C.
        • Bianchedi D.
        Arthroscopic Bankart repair and subscapularis augmentation: an alternative technique treating anterior shoulder instability with bone loss.
        J Shoulder Elbow Surg. 2016; 25: 898-906
        • Maiotti M.
        • Massoni C.
        • Russo R.
        • Schroter S.
        • Zanini A.
        • Bianchedi D.
        Arthroscopic subscapularis augmentation of Bankart repair in chronic anterior shoulder instability with bone loss less than 25% and capsular deficiency: Clinical multicenter study.
        Arthroscopy. 2017; 33: 902-909
        • Ren S.
        • Zhang X.
        • Zhou R.
        • You T.
        • Jiang X.
        • Zhang W.
        Arthroscopic subscapularis augmentation combined with capsulolabral reconstruction is safe and reliable.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 3997-4004
        • Ropars M.
        • Fournier A.
        • Campillo B.
        • Bonan I.
        • Delamarche P.
        Clinical assessment of external rotation for the diagnosis of anterior shoulder hyperlaxity.
        Orthop Trauma Surg Res. 2010; 96: S84-S87
        • Kim S.J.
        • Kim S.H.
        • Park B.K.
        • Chun Y.M.
        Arthroscopic stabilization for recurrent shoulder instability with moderate glenoid bone defect in patients with moderate to low functional demand.
        Arthroscopy. 2014; 30: 921-927
        • Baudi P.
        • Righi P.
        • Bolognesi D.
        • et al.
        How to identify and calculate glenoid bone deficit.
        Chir Organi Mov. 2000; 90: 145-152
        • Koo S.S.
        • Burkhart S.S.
        • Ochoa E.
        Arthroscopic double-pulley Remplissage technique for engaging Hill-Sachs lesions in anterior shoulder instability repairs.
        Arthroscopy. 2009; 25: 1343-1348
        • Habermeyer P.
        • Gleyze P.
        • Rickert M.
        Evolution of lesions of the labrum-ligament complex in post-traumatic anterior shoulder instability.
        J Shoulder Elbow Surg. 1999; 8: 66-74
        • Boileau P.
        • Lemmex D.B.
        Editorial commentary: Which patients are likely to undergo redislocation after an arthroscopic Bankart repair? Preoperative instability severity index scoring over 3 points. The game is over!.
        Arthroscopy. 2019; 35: 367-371
        • Lee S.H.
        • Lim K.H.
        • Kim J.W.
        Risk factors for recurrence of anterior-inferior instability of the shoulder after arthroscopic Bankart repair in patients younger than 30 years.
        Arthroscopy. 2018; 34: 2530-2536
        • Johnson S.M.
        • Robinson C.M.
        Current concepts review: Shoulder instability in patients with joint hyperlaxity.
        J Bone Joint Surg Am. 2010; 92: 1545-1557
        • Provencher M.T.
        Editorial commentary: Is it time to take a stand? When arthroscopic Bankart repair is no longer a viable option for anterior shoulder instability.
        Arthroscopy. 2018; 34: 2537-2540
        • Abrams J.S.
        • Savoie III, F.H.
        • Tauro J.C.
        • Bradley J.P.
        Recent advances in the evaluation and treatment of shoulder instability: Anterior, posterior, and multidirectional.
        Arthroscopy. 2002; 18: 1-13
        • McIntyre L.F.
        • Caspari R.B.
        • Savoie III, F.H.
        The arthroscopic treatment of multidirectional shoulder instability: Two-year results of a multiple suture technique.
        Arthroscopy. 1997; 13: 418-425
        • Saito H.
        • Itoi E.
        • Sugaya H.
        • Minagawa H.
        • Yamamoto N.
        • Tuoheti Y.
        Location of the glenoid defect in shoulders with recurrent anterior dislocation.
        Am J Sports Med. 2005; 33: 889-893
        • Milano G.
        • Saccomanno M.F.
        • Magarelli N.
        • Bonomo L.
        Analysis of agreement between computed tomography measurements of glenoid bone defects in anterior shoulder instability with and without comparison with the contralateral shoulder.
        Am J Sports Med. 2015; 43: 2918-2926
        • Alpert J.M.
        • Nikhil Verma N.
        • Wysocki R.
        • Yanke A.B.
        • Romeo A.A.
        Arthroscopic treatment of multidirectional shoulder instability with minimum 270°labral repair: Minimum 2-year follow-up.
        Arthroscopy. 2008; 24: 704-711
        • Mazzocca A.D.
        • Brown F.M.
        • Carreira D.S.
        • Hayden J.
        • Romeo A.A.
        Arthroscopic anterior shoulder stabilization of collision and contact athletes.
        Am J Sports Med. 2005; 33: 52-60
        • Carreira D.
        • Mazzocca A.D.
        • Oryhon J.
        • Brown F.M.
        • Hayden J.K.
        • Romeo A.A.
        A prospective outcome evaluation of arthroscopic Bankart repairs: Minimum 2-Year follow-up.
        Am J Sports Med. 2006; 34: 771-777
        • Wolf E.M.
        • Pollack M.
        • Smalley C.
        Hill-Sachs “Remplissage:” An arthroscopic solution for the engaging Hill-Sachs lesion.
        Arthroscopy. 2007; 23: e1-e2
        • Lafosse L.
        • Boyle S.
        Arthroscopic Latarjet procedure.
        J Shoulder Elbow Surg. 2010; 19: 2-12
        • Park J.Y.
        • Chung S.W.
        • Kumar G.
        • et al.
        Factors affecting capsular volume changes and association with outcomes after Bankart repair and capsular shift.
        Am J Sports Med. 2014; 43: 428-438
        • Dewing C.B.
        • McCormick F.
        • Bell S.J.
        • et al.
        An analysis of capsular area in patients with anterior, posterior, and multidirectional shoulder instability.
        Am J Sports Med. 2008; 36: 515-522
        • Urayama M.
        • Itoi E.
        • Sashi R.
        • Minagawa H.
        • Sato K.
        Capsular elongation in shoulders with recurrent anterior dislocation. Quantitative assessment with magnetic resonance arthrography.
        Am J Sports Med. 2003; 31: 64-67
        • Schneider D.J.
        • Tibone J.E.
        • McGarry M.H.
        Biomechanical evaluation after five and ten millimeter anterior glenohumeral capsulorrhaphy using a novel shoulder model of increased laxity.
        J Shoulder Elbow Surg. 2005; : 14318-14323
        • Meehan R.E.
        • Petersen S.A.
        Results and factors affecting outcome of revision surgery for shoulder instability.
        J Shoulder Elbow Surg. 2005; 14: 31-37
        • Turkel S.J.
        • Panio M.W.
        • Marshall J.L.
        • Girgis F.G.
        Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint.
        J Bone Joint Surg Am. 1981; 63: 1208-1217
        • Lino Jr., W.
        • Belangero W.D.
        Labrum repair combined with arthroscopic reduction of capsular volume in shoulder instability.
        Int Orthop. 2006; 30: 219-223
        • Voos J.E.
        • Livermore R.W.
        • Feeley B.T.
        • et al.
        Prospective evaluation of arthroscopic Bankart repairs for anterior instability.
        Am J Sports Med. 2010; 38: 302-307
        • Bigliani L.U.
        • Pollock R.G.
        • Soslowsky L.J.
        • Flatow E.L.
        • Pawluk R.J.
        • Mow V.C.
        Tensile properties of the inferior glenohumeral ligament.
        J Orthop Res. 1992; 10: 187-197
        • Wang V.M.
        • Flatow E.L.
        Pathomechanics of acquired shoulder instability: A basic science perspective.
        J Shoulder Elbow Surg. 2005; 14: S2-S11
        • Symeonides P.P.
        The subscapularis muscle in the pathogenesis of recurrent anterior dislocation of the shoulder.
        J Bone Joint Surg Br. 1972; 54: 476-483
        • DePalma A.F.
        • Cooke J.
        • Prabhakar M.
        Subscapularis in recurrent dislocations of the shoulder.
        Clin Orthop Rel Res. 1967; 54: 35-49
        • Saha A.K.
        • Das A.K.
        • Dutta S.K.
        Mechanism of shoulder movements and a plea for the recognition of "Zero position" of glenohumeral joint.
        Clin Orthop Rel Res. 1983; 173: 3-10
        • Klapper R.C.
        • Jobe F.W.
        • Matsura P.
        The subscapularis muscle and its glenohumeral ligament-like bands: A histomorphological study.
        Am J Sports Med. 1992; 20: 307-310
        • Itoi E.
        • Newman S.R.
        • Kuechle D.K.
        • Morrey B.
        • Fan K.
        Dynamic anterior stabilisers of the shoulder with the arm in abduction.
        J Bone Joint Surg. 1994; 76-B: 834-836
        • Magnusson S.P.
        • Simonsen E.B.
        • Aagaard
        • Johannsen F.
        • Kjaer M.
        Determinants of musculoskeletal flexibility: Viscoelastic properties, cross-sectional area, EMG, and stretch tolerance.
        Scand J Med Sci Sports. 1997; 7: 195-202
        • Halder A.
        • Zobitz M.E.
        • Schultz F.
        • An K.N.
        Structural properties of the subscapularis tendon.
        J Orthop Res. 2000; 18: 829-834
        • Gamulin A.
        • Pizzolato G.
        • Stern R.
        • Hoffmeyer P.
        Anterior shoulder instability: Histomorphometric study of the subscapularis and deltoid muscles.
        Clin Orth Rel Res. 2002; 398: 121-126
        • Tuoheti Y.
        • Itoi E.
        • Minagawa H.
        • Wakabayashi I.
        • Kobayashi M.
        • Okada K.
        Quantitative assessment of thinning of the subscapularis tendon in recurrent anterior dislocation of the shoulder by use of magnetic resonance imaging.
        J Shoulder Elbow Surg. 2005; 14: 11-15
        • Ward S.R.
        • Hentzen E.R.
        • Smallwood L.H.
        • Eastlack R.K.
        • Burns K.A.
        • Fithian D.C.
        Rotator cuff muscle architecture: Implications for glenohumeral stability.
        Clin Orth Rel Res. 2006; 448: 157-163
        • Werner C.M.L.
        • Favre P.
        • Gerber C.
        The role of the subscapularis in preventing anterior glenohumeral subluxation in the abducted externally rotated position of the arm.
        Clin Biomech. 2007; 22: 495-501
        • Edelson J.G.
        • Taitz C.
        • Grishkan A.
        The coracohumeral ligament. Anatomy of a substantial but neglected structure.
        J Bone Joint Surg Br. 1991; 73: 150-153
        • Bernhard J.
        • Koch P.P.
        • Gerber C.
        Anatomy and functional aspects of the rotator interval. 2000.
        J Shoulder Elbow Surg. 2000; 9: 336-341
        • Bennett F.W.
        Subscapularis, medial, and lateral head coracohumeral ligament insertion anatomy.
        Arthroscopy. 2001; 17: 173-180
        • Russo R.
        • Della Rotonda G.
        • Cautiero F.
        • et al.
        Arthroscopic Bankart repair associated with subscapularis augmentation (ASA) versus open Latarjet to treat recurrent anterior shoulder instability with moderate glenoid bone loss: clinical comparison of two series.
        Musculoskelet Surg. 2017; 101: 75-83
        • Ahmadain A.M.
        The Magnuson-Stack operation for recurrent anterior dislocation of the shoulder.
        J Bone Joint Surg Br. 1987; 69-B: 111-114
        • Salomonsson B.
        • Abbaszadegan H.
        • Revay S.
        • Lillkrona U.
        The Bankart repair versus the Putti-Platt procedure. A randomized study with WOSI score at 10-year follow-up in 62 patients. 2009.
        Acta Orthop. 2009; 80: 351-356
        • Schröter S.
        • Krämer M.
        • Welke B.
        • et al.
        The effect of the arthroscopic augmentation of the subscapularis tendon on shoulder instability and range of motion: A biomechanical study.
        Clinical Biomechanics. 2016; 38: 75-83
        • Klungsovr P.J.
        • Guldal F.
        • Vagstad T.
        • Klungsovr J.A.
        A new subscapularis sling operation to stabilize the shoulder.
        J Exp Orthop. 2015; 2: 1-9
        • Tibone J.
        Editorial commentary: Not for the faint of heart: The arthroscopic Latarjet procedure, a North American experience.
        Arthroscopy. 2016; 32: 1971-1972