Abstract
The approach to revision after an arthroscopic Bankart is a controversial topic. Several studies have shown an increased failure after revision compared with primary procedures, and many papers have recommended an open approach with or without bone augmentation. It seems intuitive that if an approach fails, that we ought to try a different one. And yet we do not. When facing this condition, it is far more common that we talk ourselves into performing another arthroscopic Bankart. It’s relatively easy, familiar, and comforting. We find a reason to give this operation one more chance due to some patient-specific factor, like bone loss, number of anchors, or contact athlete status. Recent research shows that none of these factors matter, yet many of us find something that leads us to conclude that in our hands, with this patient, this time, the surgery will work. As data continue to emerge, the indications for this approach continue to narrow. It is becoming increasingly difficult to find a reason to go back to this operation as our best choice for the failed arthroscopic Bankart.
Like a devil on my shoulder you keep whisperin' in my ear
And it's gettin' kinda hard for me to do the right thing here
I wanna do the right thing, baby
'Cause I know you and you know me
And we both know where this is gonna lead
You want me to say that I want you to stay
So you should probably leave…-Chris Stapleton, You Should Probably Leave, 2020
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Cautionary art seeks to tell a story meant to inspire our better angels to guard against the universal attraction to self-destruction. No genre is more committed to this than American country music. It remains so popular in part because it tells stories about universal human themes. Many of the best are about bad decisions, loss, and regret.
An old joke goes something like, “do you know what happens if you play a country music song backwards?” (Answer: “you get your dog back, you’re sober, your truck runs right, and your wife doesn’t leave you.”)
Why do we give bad relationships so many chances? We tell ourselves that “It’ll be different this time.” Somehow, however, it ends up the same way.
Like the perfect country song—or the revision arthroscopic Bankart.
In the article, “Revision Arthroscopic Bankart Repair Results in High Failure Rates and a Low Return to Duty Rate Without Recurrent Instability” by Slaven, Donohue, Tardif, Foley, LeClere, Cameron, Giuliani, Posner, and Dickens,
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you can almost hear the steel guitar and taste the whiskey as the authors sing a song that is beautifully written but takes you to the inevitable bar stool of failure and regrettable decisions. The authors report a 44% failure rate in a population of young active-duty patients treated for failed shoulder stabilization. This is revision surgery, which means they have failed this relationship before, and the average age of these patients is younger than 23 years. The abstract reads like a George Jones/Tammy Wynette collaboration. But, like each generation of country music fans, we want to believe the relationship can be salvaged: When its good, it’s so good—Stand by your man
And show the world you love him
Keep giving all the love you can, mm, mm
Stand by your man, hmm, hmm-Tammy Wynette, Stand by Your Man, 1968
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So, we start looking for reasons we can make this work. Maybe the authors failed to consider a key confounder that would prove their conclusions too harsh? Did they take into consideration bone loss? (Sorry, they excluded glenoid bone loss >20%, and the glenoid bone loss in the failure group and successful group were not different and both approximately 6%.)
What about the track concept? We know arthroscopic Bankart repairs don’t work in off-track lesions,
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so maybe these failed due to a high percentage of the failures being “off track!” (Unfortunately for us, the authors considered this as well. Both groups had a Hill–Sachs lesion in 83% of cases, and the percentage of off-track lesions [13% vs 11%] was not different between groups.) In fact, this is one of the most pivotal findings of the study: revision arthroscopic Bankart repairs fail, but we can’t blame it on bone loss.…But in the morning light, the lies reveal the truth
Yeah the sober truth
We wake up to reality
And play the blame game ruthlessly
Like it would’ve turned out different
If we would’ve stopped at one or two
But don’t blame it on the whiskey-Jon Pardi, Don't Blame it on the Whiskey, 2019
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In fact, most of the reasons we might use to talk ourselves into giving this operation another chance are nicely addressed by the authors: number of anchors, age at time of surgery, index additional procedures, and contact/collision status were all similar between the groups. The only thing that approached statistical significance between the successful and unsuccessful groups was the duration of follow up, noting that the longer the follow-up, the more likely it was to fail.
Pass the whiskey.
Maybe we are the problem? If we were more open to other relationships, maybe things wouldn’t fail? Perhaps. Although Slaven et al.
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do not have a comparative group of other techniques in this paper, others do. Lau et al.6
published a recent systematic review of outcomes after revision stabilization. They found the rate of recurrent instability was 4% after the Latarjet procedure, 13% after open repair, and 16% after arthroscopic repair. The current study seems to be an outlier, with a failure rate 2.5 times that of the rest of the literature. Why?Perhaps the populations are different. Bull riders are different than ropers, and perhaps the Slaven population of active-duty military members is just “built different” than these other studies. There is some evidence to support this as well. In a separate systematic review, Lau et al.
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evaluated return to sports after revision stabilization as their main metric, which more closely resembles what is required for success in the active-duty military. They found return to previous level only averaged between 60% and 70%–for all techniques. Of note, this rate was not different between revision arthroscopic Bankart (70%) and Latarjet (67%), suggesting that who we operate on is as important a factor as what we are operating on:Some things that I do, I know don’t please you
My ways are rowdy and rough
Don’t try to change me, you can’t rearrange me
Cowboys ain’t easy to love-Chris Ledoux, Cowboys Ain't Easy to Love, 1978
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So where does this leave us? Slaven et al.
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deserve a lot of credit for honestly reporting their findings. This is cautionary art from an institution and a group of authors that perform this operation as well as it can be performed. Their song ends, however, with a familiar twang; At least in an active population, giving the arthroscopic Bankart another chance is a bad idea. There’s no other way to sing it. And, until we start really listening to the music, we will keep finding ourselves trying to figure out what went wrong.Press play.
But don't think I don't think about it
Don't think I don't have regrets
Don't think it don't get to me
Between the work and the hurt and the whiskey
Don't think I don't wonder 'bout
Could've been, should've been all worked out
I know what I felt, and I know what I said
But don't think I don't think about it-Darius Rucker, Don’t Think I Don’t Think About It, 2008
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References
- You Should Probably Leave. Starting Over.Mercury Nashville, Nashville, TN2020
- Revision arthroscopic Bankart repair results in high failure rates and a low return to duty rate without recurrent instability.Arthroscopy. 2023; 39: 913-918
- Tammy. Stand By Your Man. Stand By Your Man.Columbia Recording Studios, Nashville, TN1968
- Clinical validation of the glenoid track concept in anterior glenohumeral instability.J Bone Joint Surg Am. 2016; 98: 1918-1923
- Don’t Blame It on the Whiskey. Heartache Medication.UMG Recordings, Nashville, TN2019
- Outcomes after revision anterior shoulder stabilization: A systematic review.Orthop J Sports Med. 2020; 82325967120922571
- Return to play after revision anterior shoulder stabilization: A systematic review.Orthop J Sports Med. 2021; 92325967120982059
- Cowboys Ain't Easy to Love. Cowboys Ain't Easy to Love.Chris LeDoux, Nashville, TN1978
- Don't Think I Don't Think About It. Learn To Live.Capitol Nashville, Nashville, TN2008
Article info
Footnotes
See related article on page 913
The author reports the following potential conflicts of interest or sources of funding: grants or contracts from Arthrex and DePuy Mitek; royalties or licenses from Arthrex; consulting fees from Arthrex; payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing, or educational events from Arthrex; support for attending meetings and/or travel from Arthrex; and leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid: AANA. In addition, the author has patents planned, issued, or pending for the biologic use of Amnion. Full ICMJE author disclosure forms are available for this article online, as
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