Keywords
shoulder - joint instability - arthroscopy - recurrence
Introduction
Arthroscopic Bankart surgery has shown fewer complications, reduced surgical time,
lower morbidity, and less postoperative pain when compared with open surgery.[1]
[2]
[3] However, its results deteriorate over time. If, in the short follow-up, the recurrence
ranges between 8 and 11%, in the long follow-up, they are between 12.5 and 35%.[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
The purpose of the present study is to evaluate the recurrence rate and the factors
predisposing to its occurrence in patients submitted to arthroscopic repair of Bankart
lesions with a minimum follow-up of 10 years. Secondly, the study seeks to identify
whether there was an improvement in functional scores with surgery. We believe that
relapse rates are close to 30% and that there are predisposing factors to surgical
failure.
Materials and Methods
The present study was approved by the Research Ethics Committee and did not receive
funding for its realization. The patients registered their consent through the free
and informed consent form.
The present study retrospectively analyzed patients submitted to arthroscopic Bankart
surgery as a primary form of treatment of recurrent anterior shoulder instability
from January 1996 to November 2009. The evaluations at the end of the follow-up period
were made through a new summoning of the patients. Patients with a minimum follow-up
of 10 years who presented a complete record of their information were included. Patients
with complete associated rotator cuff rupture were excluded, along with those who
had a glenoid bone loss > 25% measured by radiography in the incidence of Bernageau
profile,[16] in addition to those diagnosed with multidirectional instability and those unable
to complete all evaluations.
The measurement of glenoidal bone loss was performed using the Bernageau profile method,
as described in his work, evaluating the affected side through the image of the "strict
profile" of the glenoid. For this, the lower two thirds of the glenoid were divided
into 4 equal parts and, thus, the percentage of bone loss was measured as < 25%, between
25 and 50%, between 50 and 75%, or > 75%.[16]
To evaluate osteoarthrosis, the patients underwent shoulder x-rays at true anteroposterior
incidence with the arm in neutral rotation. The results were classified into 3 types,
according to Samilson et al.:[17] mild – osteophyte < 3 mm; moderate – osteophyte from 3 to 7 mm and mild irregularity
of the joint surface; severe – osteophyte > 7 mm, loss of joint space, and bone sclerosis.
All procedures were performed in lateral decubitus under general anesthesia and brachial
plexus block. Three arthroscopic portals (posterior, anterosuperior and anteroinferior)
and 30° optics were used. The repair of the lesions was performed with 3.5 mm metal
anchors loaded with high-strength wires.
Information such as gender, laterality, dominance, sports practice (pre- and postoperative),
type of sport (contact or contactless), level of participation (amateur or professional),
mechanism of trauma, and age at the first episode of instability were collected from
medical records. The time elapsed between the first episode of instability and surgical
treatment was also recorded, as well as the age at which the procedure was performed,
the number of recurrences until its performance, and the return to sports practice.
For functional evaluation, the Carter-Rowe and the University of California, Los Angeles
(UCLA) scores were used.[18]
[19] The first was comparatively evaluated before and after the surgical procedure. The
second was evaluated only postoperatively. The results of the UCLA score were grouped,
being considered excellent scores 34 and 35, good 28 to 33, regular 21 to 27, and
bad < 20. Regarding the Carter-Rowe score, it was considered an excellent result when
the score was between 90 and 100, good between 75 and 89, reasonable between 51 and
74, and bad when < 50 points.
The physical examination of the patients at the end of the follow-up included the
comparative measurement of the lateral rotation of the right and left shoulders with
the limb abducted close to the body and the use of a goniometer. They were also submitted
to the previous apprehension test, and impending joint instability was considered
as positivity. The presence of pain was not considered as a positive result of the
test. Capsule-ligamental hyperlaxity analysis was performed according to the criteria
of Beighton et al.[20] This condition was defined by a score ≥ 4.
The occurrence of a new episode of dislocation or of subluxation was considered a
criterion for postoperative recurrence. The persistence of positivity in the apprehension
test was recorded without the presence of recurrence, emphasizing that positivity
alone in this test was not considered a failure in our study.
The statistical evaluation was divided into descriptive, association, and logistic
regression analyses. Data analyses were performed using IBM SPSS Statistics for Windows,
version 23 (IBM Corp., Armonk, NY, USA). The tests used to analyze the associations
of qualitative variables were the Pearson chi-squared test and the Monte Carlo test,
when necessary. The Kruskall-Wallis test and the Mann-Whitney U test were used to
analyze the associations of quantitative variables. Multiple logistic regression was
used to identify the main risk factors associated with recurrence. The significance
level used in the entire study was of 5%.
Results
After applying the inclusion and exclusion criteria, 41 patients (45 shoulders) were
included in the sample. The mean follow-up time was 14.89 years (minimum of 10 years
and maximum of 23 years). The qualitative and quantitative variables can be observed
in [Tables 1 ] and [2]. Recurrences totaled 22.20% (9 dislocations and 1 subluxation), and in 2 of these
cases there, were bone Bankart lesions < 25% of the glenoid, and both evolved with
dislocation. At the end of the follow-up, four patients had a positive apprehension
test.
Table 1
|
Variable
|
|
n
|
%
|
|
Gender
|
Male
Female
|
34
7
|
82.92
17.07
|
|
Laterality
|
Right
Left
|
23
22
|
51.11
48.89
|
|
Dominance
|
Right-handed
Left-handed
|
35
6
|
85.36
14.63
|
|
Hyperlaxity
|
Yes
No
|
2
39
|
4.87
95.12
|
|
Sports practice
|
Yes
No
|
33
8
|
80.48
19.51
|
|
Type of sport
|
Contact
Non-Contact
|
17
16
|
51.51
48.48
|
|
Level of sports practice
|
Amateur
Professional
|
23
10
|
69.69
30.30
|
|
Trauma mechanism in the first episode
|
Trauma
Seizure
Other
|
42
1
2
|
93.33
2.22
4.44
|
Table 2
|
Variable
|
n
|
Average
|
Standard deviation
|
Minimum
|
Maximum
|
|
Age at the first episode of dislocation (years)
|
45
|
28.60
|
11.35
|
12.00
|
62.00
|
|
Time between first episode and surgery (years)
|
45
|
3.37
|
5.32
|
0.04
|
25.00
|
|
Number of relapses before surgery
|
45
|
8.60
|
8.48
|
1.00
|
30.00
|
|
Age at surgery (years old)
|
45
|
31.76
|
11.10
|
18.00
|
63.00
|
|
Time between surgery and relapse (years)
|
10
|
5.40
|
3.47
|
1.00
|
10.00
|
|
Age at relapse (years)
|
10
|
34.20
|
9.13
|
24.00
|
49.00
|
|
Number anchors
|
45
|
3.13
|
0.73
|
2.00
|
5.00
|
|
Lateral rotation limitation (degrees)
|
45
|
7.38
|
8.59
|
0.00
|
30.00
|
The results of the Carter-Rowe score are shown in [Table 3.] There was an improvement of 46.11 points on average (39.79 to 85.89 points). At
the end of the follow-up, the UCLA score totaled 31.33 points on average. Considering
this score, 19 patients presented excellent results, 17 were classified as good, 7
had regular results, and only 2 had poor results ([Table 4]).
Table 3
|
Carter-Rowe
|
|
Preoperative
|
Postoperative
|
|
Excellent
|
1
|
34
|
|
Good
|
1
|
2
|
|
Reasonable
|
5
|
0
|
|
Bad
|
38
|
9
|
|
Total operated shoulders
|
45
|
45
|
Table 4
|
Variable
|
n
|
%
|
|
UCLA categorized
|
Bad
|
2
|
4.44
|
|
Regular
|
7
|
15.56
|
|
Good
|
17
|
37.78
|
|
Excellent
|
19
|
42.22
|
Arthrosis was absent in 41 shoulders (91.11%) in the preoperative period. At the end
of the follow-up, 19 shoulders (42.23%) of operated patients had arthrosis, with 16
cases (35.56%) being type 1, 3 cases (6.67%) type 2, and no type 3 cases ([Table 3]).
At the end of the follow-up, 75.56% of the patients returned to sports practice, being
predominantly contactless sports (61.76%) and amateur level (52.94%).
A statistically significant association was observed between the number of episodes
of instability before surgery and failure of the Bankart procedure (p = 0.019).
Multiple binary logistic regression analysis showed that each recurrence of instability
preoperatively is associated with an increase in the chance of surgical failure by
1.118 times (95% confidence interval [CI]: 1.0–1.2; p = 0.012).
Discussion
The present study showed a failure rate of 22.22% in arthroscopic Bankart surgery
at the end of the ten-year minimum follow-up; on average, the failure occurred 5.4
years after surgery. This finding is consistent with the literature, which presents
failure rates of between 12.5 and 35% when evaluated in the long-term.[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
The literature shows that 50% of recurrences occur in the first 2 years after the
procedure, with an increase of 25% at the end of 5 years.[6]
[15]
[21] This information was confirmed by evaluating the arthroscopic repair of Bankart
lesions with a minimum follow-up of 2 years performed by our group, which observed
8.9% of failures and residual apprehension in 2.2%,[5 ] and another national study with the same follow-up time found rates of 11.7 and
24.46%, respectively.[22] It is noteworthy that the evaluation criteria are divergent and some authors consider
a persistently positive apprehension test indicative of recurrence.[23] This factor was not considered in our study.
Several authors have demonstrated a satisfactory functional gain with arthroscopic
Bankart surgery when evaluated in long-term follow-up. Considering the Carter-Rowe
score postoperatively, our study found at the end of the evaluation period an average
of 85.89 points, and this value is consistent with the results of other authors, whose
mean ranged from 76.0 to 90.5 points.[7]
[8]
[13]
[24]
[25] Regarding the UCLA score at the end of the follow-up, our group found an average
of 31.33 points, similar to the value found by Castagna et al.,[8] who obtained an average of 32.1 points at the end of the evaluation period.
Aboalata et al.[7] demonstrated a direct relationship between surgical recurrences and the number of
episodes of preoperative dislocations. Our study confirmed this trend with statistical
significance and corroborates the importance of early surgical intervention. This
proposal aims to reduce recurrences and consequent bone losses of the glenoid, already
observed by several authors as a negative influence factor on the outcome of Bankart
surgery.[26]
[27]
[28] Its impact can be observed in our results that found dislocation at the end of the
follow-up in the 2 cases of the sample with bone Bankart.
Of the patients in the sample, 42.23% developed osteoarthrosis secondary to Bankart
arthroscopic repair, a value similar to that reported in the literature, in which
rates range from 39 to 80%.[8]
[10]
[23]
[29]
[30]
In our opinion, the present study is the first in the national literature to report
the results of arthroscopic Bankart with a minimum follow-up of 10 years. The main
limitation refers to the retrospective character consisting of a series of cases composing
a small sample, treated surgically at a time when the effects of bone losses on recurrences
were underestimated and poorly quantified by the methods used.
Conclusions
In a minimum follow-up of 10 years, the recurrence rate of the arthroscopic Bankart
procedure was of 22.20%, similar to that described in the literature. The number of
preoperative recurrences was the main impacting factor in failures after surgery.
Table 5
|
Variable
|
n
|
%
|
|
Preoperative Samilson
|
Absence of arthrosis
|
41
|
91.11
|
|
Mild arthrosis
|
4
|
8.89
|
|
Samilson at the end of the follow-up
|
Absence of arthrosis
|
26
|
57.78
|
|
Mild arthrosis
|
16
|
35.56
|
|
Moderate arthrosis
|
3
|
6.67
|
