Systematic Review of Arthroscopic Bankart Repair Outcomes for Anterior Shoulder Instability

Introduction

The shoulder is a complex joint, where stability has been sacrificed in favor of range of motion [1]. The shoulder joint has the largest range of motion among all joints [2], making the joint more liable to dislocate following the injury of the anterior labrum, which is the master stabilizer of the glenohumeral joint [3,4]. A traumatic shoulder dislocation is often accompanied by a labral lesion, which predisposes the patient to develop chronic shoulder instability [5]. Primary shoulder dislocation incidence varies between 15.3 and 56.3 per 100 000 individual-years [6,7]. In sports medicine, anterior instability of the shoulder joint is quite prevalent, particularly in athletes, young men, and military people, who experience dislocations at a rate as high as 3% per year [8,9]. The incidence of anterior shoulder instability in the general population ranges from 8% to 25% per 100 000 person-years [10].

Shoulder instability occurs when the structures that keep the shoulder joint in place are damaged or weakened, often due to trauma, repetitive strain, or congenital factors, such as hypermobility. More recently, biomechanical research has shown that following a single dislocation of the shoulder joint complex, abnormal biomechanics alter, and the likelihood of recurrent instability rises; these disturbances in the kinetics compound with further dislocations [11,12]. These long-term biomechanical alterations and the dose-dependent effects of numerous instability events support early surgical stabilization to lower recurrence and maximize function [13–15].

Management involves a combination of non-surgical and surgical approaches. Non-surgical treatment typically includes physical therapy to strengthen the shoulder muscles, activity modification, and possibly bracing. If instability persists or is severe, surgical intervention can be required to repair or reconstruct the damaged structures. The acute treatment of shoulder dislocation is closed reduction and should be performed as soon as possible. Stabilization can be indicated following the first dislocation. Most patients with chronic post-traumatic shoulder instability are offered to undergo stabilization surgery [5].

Conservative treatment of anterior instability of the shoulder joint can result in a high recurrence rate of 87% in patients at high risk after the first episode of dislocation [16]. Even in situations with bipolar bone loss, open Bankart repair has been proven to be a durable choice, with a recurrence rate of less than 1% at short and long follow-ups [17,18]. Bankart repair focuses on the anatomical re-attachment of the labrum to the glenoid rim [2].

During the arthroscopic Bankart repair (ABR), small incisions are made around the shoulder, and an arthroscope is inserted to visualize the joint. Using specialized instruments, the surgeon reattaches the torn labrum to the socket, typically with the help of anchors or sutures. Because of its minimally invasive nature and capacity to treat concurrent injuries, ABR has largely replaced open Bankart repair during the past few decades, particularly in cases of minor glenoid or humeral bone loss [19]. Most surgeons favor ABR as the first surgical treatment for anterior shoulder instability, as it is the most frequently performed surgical operation worldwide [20]. ABR has raised concerns since, according to published research, it produced significant rates of instability recurrence of up to 40% [21]. Appropriate patient selection, the state of the preserved soft tissue, and careful surgical technique – including the positioning of suture anchors and the quantity of sutures passed – are all necessary for successful outcomes in ABR [22]. Therefore, this systematic review was performed to evaluate the effects of ABR in the management of anterior shoulder instability and in comparison with other interventions, to study the evidence of its effectiveness.

In this systematic review, we compiled and examined the existing data on ABR, offering a thorough assessment of the treatment’s efficacy. As a result, we can offer healthcare professionals the most recent and trustworthy data to support clinical judgments about the application of ABR. In systematic reviews that gather data, ABR is frequently compared with other therapy options for shoulder instability, such as open Bankart repair, conservative care, or other surgical procedures. By comparing the advantages and disadvantages of various treatment choices, this comparative analysis can aid physicians and patients in making well-informed decisions. In conducting this systematic review, we offer a methodical and thorough way to assess the results of ABR in treating shoulder instability, which will eventually help guide future research, educate clinical judgment, and enhance patient care. Therefore, this systematic review aimed to evaluate the published literature on arthroscopic Bankart repair for anterior shoulder instability.

Material and Methods

INFORMATION SOURCES, SEARCH STRATEGY AND SELECTION PROCESS:

This systematic review follows the PRISMA checklist guidance [23]. We searched via electronic databases, including Google Scholar, PubMed, SciElco, Science Direct, Scopus, and PubMed, to find literature about our topic. A group of different keywords were used for searching purposes, including “ABR, shoulder, instability, dislocation, treatment, management, recurrence, outcomes, complications”, which were used in different combinations to obtain all possible related articles. The search process was restricted to articles published in English from 2018 till 2023.

ELIGIBILITY CRITERIA:

The titles generated by this initial investigation were all rewritten using the following criteria: first, duplicate articles and articles on recurrent patients were eliminated as indicated by the titles; second, the study design was reviewed for each article through the titles and abstract to include only the original articles and exclude other types, like reviews, case reports, systematic reviews, meta-analyses, and letters to the editor; third, the articles were checked for language and full-text availability; non-English articles and those not available for full text were excluded; and, lastly, only original English articles with full-text availability were included.

SYNTHESIS METHOD:

The full data of each article was checked, and articles containing incomplete data were excluded. The illustration of the search strategy is shown in Figure 1.

DATA REVIEW AND ANALYSIS:

Using a specially created Excel sheet, a preliminary assessment was conducted to identify the data of relevance for data extraction. After selected data from eligible articles were edited using the Excel sheet, they were moved to a table that had already been prepared for summarization.

Results

STUDY SELECTION:

This systematic review included 8 studies that met the eligible criteria [24–31] (Table 1). Three studies did not report the study design [25,30,31]; the remaining 5 studies were a prospective randomized trial [24], randomized controlled trials [26,27], longitudinal, observational, and retrospective trial [28], and retrospective review [29]. Four studies [28–31] assessed ABR alone to assess the outcomes and risk factors of recurrence of the procedure [28], assess outcomes, including recurrence among female patients [29], assess the clinical outcomes of 2 types of sutures [30], and assess recurrence rate and risk factors [31], respectively. The remaining 4 studies involved ABR and other interventions [24–27]. The first study compared ABR and open Latarjet [24], the second study compared ABR with and without concomitant remplissage [25], the third study compared ABR and immobilization [26], and the last study compared ABR and immobilization in 60° of external rotation and 30° of abduction [27].

STUDY CHARACTERISTICS:

A total of 398 patients were included in the 8 studies. One study included 30 male patients [24], and another study included 31 female patients [29]. The remaining 6 studies included male and female patients. Three studies involved 1 group of patients [28,29,31], whereas the remaining 5 studies included 2 groups of patients for comparison [24–27,30].

One study enrolled patients with traumatic anterior shoulder instability with minimal glenoid bone loss [24], and another 2 studies enrolled patients with traumatic anterior shoulder instability [30,31]. Three studies enrolled patients with anterior instability of shoulder joint [25,28,29], and 2 studies included patients with the first incidence of anterior dislocation of the shoulder joint [26,27]. The age of patients ranged from 15 years [31] to 55 years [25,30]. One study did not report the duration of follow-up [31], whereas in the remaining 7 studies, the minimum duration of follow-up was 13.27 months [24], and the maximum duration was 84 months (7 years) [28].

RESULTS OF INDIVIDUAL STUDIES:

The studies reported heterogeneous results, due to their differences in objectives and populations. Therefore, the findings of studies that assessed ABR alone are illustrated first, as follows [28–31]. The study conducted on female patients revealed that 82% of patients returned to sport and 58% of them returned to the same or higher level. The rate of complication was low, as the recurrent rate of instability was 8.8%, recurrence of dislocation was experienced by 2.9%, and 5.9% experienced recurrent subluxation [29]. The other study conducted on ABR reported only a low recurrence rate of 9.8%, and the associated factors by multivariate analysis included large Hill-Sachs lesions (OR=6.75) and less than 4 suture anchors (OR=9.45) [31]. One of the other 2 studies assessed ABR with suture with no mention of the suture type. The study showed a low recurrence rate of 9.4%, whereas 54.3% of the patients achieved excellent or good results. A complete range of motion was achieved among 90% of patients, and the complication rate was low among the 4.88% who experienced advanced osteoarthritis [28]. The last study, which compared all-soft suture anchor and conventional metal anchor, showed that both types resulted in comparable clinical and functional results, and both types resulted in significant increases in American Shoulder and Elbow Surgeons (ASES) and Latarjet scores, concomitant remplissage Latarjet scores, and concomitant remplissage scores after ABR. However, no significant differences were found between the 2 types regarding ASES score (P=0.2), Rowe score (P=0.4), the change in ASES% (P=0.4), and the change in Rowe% (P=0.2) [30].

RESULTS OF SYNTHESES:

The other 4 studies compared ABR with other interventions [24–27]. One study comparing ABR and Latarjet found that postoperative range of motion and Rowe scores did not differ between the 2 methods, and none of the patients experienced recurrent dislocation. Latarjet was better than ABR regarding significantly lower time to return to sport (5.2 vs 7 months for Latarjet and ABR, respectively), but ABR was better regarding significantly shorter operative time (43.33 vs 72.33 for ABR and Latarjet, respectively). Additionally, open Latarjet is a more invasive and non-anatomical procedure [24]. ABR with and without concomitant remplissage showed similar results; both methods resulted in the same rate of glenoid bone loss (11%), close rate of recurrence of dislocation with no significant difference, and no difference in the rate of return to sport, range of motion, and complications, including subjective instability, reoperation, or revision (all P values were >0.05). The only significance was regarding the engagement of Hill-Sachs lesions, as they were more prevalent among patients who underwent remplissage than in those without remplissage [25]. The remaining 2 studies compared ABR with immobilization. One study reported that ABR resulted in better outcomes regarding a lower rate of recurrence (P=0.0001), fewer episodes of dislocation, lower complications, including subluxation (P=0.003), and a higher rate of return to sport at the same or better level (P=0.012). Additionally, the ABR group showed a higher Walch-Duplay score (P=0.035), with no surgical complications and no significant difference in range of motion [26]. The last study compared ABR with immobilization, but immobilization was in external rotation and abduction. The recurrence rate was lower in the ABR group (P=0.01), with no significant difference in clinical shoulder score (P>0.05) [27].

Discussion

LIMITATIONS OF THE STUDY AND FUTURE SUGGESTIONS:

There was a lack of data on risk factors in the studies included in this systematic review. Some studies had a relatively short duration of follow-up, which does not capture long-term outcomes accurately. The systematic review included a limited number of 8 studies, which can restrict the generalizability of the findings and the ability to draw strong conclusions. The included studies had different designs, such as prospective randomized trials, retrospective reviews, and observational studies, which could introduce bias and affect the consistency of the results. Some comparisons, such as between ABR and Latarjet, were based on a single study, which may not provide a comprehensive understanding of the comparative effectiveness of different interventions. Hence, we recommend a systematic review of randomized controlled trials that includes a greater number of studies.

Conclusions

ABR was effective in the management of shoulder instability, as it resulted in a lower rate of recurrence, low rate of complications, and high rate of return to sport, regardless of the suture type. ABR was also superior to the conservative method, as it resulted in lower recurrent rare complications, with no surgical complications. Also, combining concomitant remplissage with ABR showed no superior outcomes. Furthermore, when Latarjet was compared with ABR, Latarjet was superior regarding a reduced time to return to sport, whereas ABR was better regarding a shorter operative time. A shorter operative time is necessary, as a long operative time carries an increased risk of the patient getting infection. The current evidence for the effectiveness and superiority of ABR is weak, due to variations in results. Although the studies reported the superiority of ABR compared with conventional immobilization and other interventions, such as Latarjet and combined concomitant remplissage, there is a lack of recent studies performing such comparisons, and strong evidence will require the analysis of more studies without such heterogeneous variations in study design and other variables.