Management of Recurrent Anterior Shoulder Instability with Open Bankart Labral Repair
A 20-year-old Division I college football player with recurrent anterior shoulder instability has persistent instability 2 years after arthroscopic labral repair, which involved a small bony Bankart lesion. Will open Bankart repair resolve his symptoms?
William Emper, MD, and Zaira Chaudhry, MPH
The authors have no disclosures relevant to this article.
The incidence of shoulder dislocations in the United States is estimated to be 23.9 per 100,000 person-years, with males between the ages of 15 and 29 years most commonly affected.  Moreover, 48.3% of injuries resulting in shoulder dislocation occur during sports or recreational activities. 
Several studies have demonstrated an inverse relationship between age at the time of the initial dislocation and risk of recurrent shoulder instability. In a 10-year prospective study of 247 patients, Hovelius et al  found the following rates of recurrent instability based on age at the time of the primary dislocation:
- 66% for patients 12 to 22 years old
- 56% for patients 23 to 29 years old
- 24% for patients 30 to 40 years old
Considering the high risk of recurrence, surgical intervention may be required to treat anterior shoulder instability, especially when encountered in young, active patients who are particularly predisposed to recurrent dislocation. The most common injury pattern is a Bankart lesion or an avulsion of the anterior inferior portion of the glenoid labrum from the glenoid rim, which may be associated with an anterior or posterior glenoid rim fracture (bony Bankart).
A 20-year-old Division I college football player with recurrent anterior instability of the left shoulder presented to our practice.
The patient had undergone an arthroscopic labral repair in high school for a labral tear, which involved a small bony Bankart lesion. Two years after this procedure, he developed recurrent shoulder instability and had 2 or 3 episodes of subluxation.
He has noted a sensation of increasing instability even with minimal activity, such as overhead motion while lying in bed.
- BMI: 32.1 kg/m2
- Full symmetric range of motion
- Positive anterior apprehension and relocation test
- Negative sulcus sign
- Normal strength
- Normal neurologic examination
- X-ray demonstrated a possible small anterior inferior glenoid bone loss.
- MR arthrogram revealed evidence of previous anterior inferior labral repair with a small bony Bankart lesion and significant granulation tissue on the anterior-inferior joint (Figure 1).
- CT scan confirmed the presence of a small anterior inferior bony Bankart fracture with a posterior Hill-Sachs lesion (Figure 2).
Figure 1. Preoperative MR arthrogram.
Figure 2. Preoperative CT scan.
The CT scan revealed a bony Bankart involving less than 10% glenoid bone loss and a small humeral Hill-Sachs lesion. It was determined that these lesions were too small, either independently or in combination, to warrant augmentation procedures to either the anterior glenoid or the posterior humerus.
This preoperative assessment could be further evaluated using the on-track/off-track method described by Di Giacomo et al.  Although a formal assessment with the appropriate imaging to demonstrate glenoid tracking is not available for this case, it is worth highlighting the utility of this imaging parameter.
Di Giacomo et al  described the on-track/off-track method to evaluate Hill-Sachs lesions and glenoid bone loss simultaneously with 3-dimensional CT imaging. Using the width of the Hill-Sachs lesion and the size of the glenoid track, the on-track/off-track method can preoperatively assist in predicting whether a Hill-Sachs lesion will engage to the anterior glenoid rim. Hill-Sachs lesions that engage are considered “off-track” lesions, whereas those that do not engage are considered “on-track” lesions.
Di Giacomo et al  recommend additional humeral-sided procedures (humeral bone graft or remplissage) for treating off-track lesions.
- Recurrent anterior instability of the left shoulder, failed arthroscopic labral repair, and small bony Bankart, less than 10% glenoid bone loss
- The patient was placed in the beach chair position following induction of anesthesia (Figure 3).
- Arthroscopic evaluation documented previous anterior inferior labral repair, bony Bankart involving less than 10% glenoid bone loss, minimal Hill-Sachs lesion, and no additional labral pathology.
- Open Bankart labral repair was performed through a 5-cm anterior incision, extending just lateral from the coracoid to the axilla (Figure 4).
- Deltopectoral dissection was performed, while protecting the cephalic vein laterally, to expose the conjoined tendon. The tendon was carefully retracted medially (Figure 5).
- The subscapularis was dissected off the anterior capsule, providing exposure for a T-shaped capsulotomy based laterally. Sutures were placed in the subscapularis for repair on closure (Figure 6).
- The anterior inferior glenoid was exposed and debrided with a high-speed burr.
- The anterior inferior labral repair was performed with 3 suture anchors placed at 3, 4, and 5 o’clock.
- The capsule was plicated laterally and repaired back to the humeral neck with the arm in 45o of abduction and external rotation.
- All anchors used in this case were Q-Fix suture anchors (Smith & Nephew, Andover, Massachusetts) and #2 Ultrabraid (Smith & Nephew) placed in a horizontal mattress fashion.
- The subscapularis was directly repaired to its origin with #2 Ultrabraid suture.
Figure 3. Patient in the beach chair position.
Figure 4. A 5-cm anterior incision was extended laterally from the coracoid to the axilla.
Figure 5. Deltopectoral dissection exposed the conjoined tendon.
Figure 6. Dissection of the subscapularis off the anterior capsule allows adequate exposure for a T-shaped capsulotomy.
Postoperative Course and Follow-up
Immediately following surgery, the patient was placed in a sling and pillow and allowed external rotation to neutral with elbow motion. Formal physical therapy was initiated at 4 weeks, progressing to full range of motion. Strengthening exercises began at 12 weeks.
The patient transitioned to a supervised strength and conditioning program at 4 months after surgery and then returned to full sports activity and football at 6 months. He wore a protective neoprene shoulder sleeve for the first postoperative year. He played 3 more years of Division I college football with no further episodes of instability.
He currently has full range of motion and no pain or instability with athletic activities.
Surgical management of recurrent anterior shoulder instability continues to evolve. The open Bankart procedure was considered the gold standard, with favorable long-term outcomes noted in up to 98% of patients.  However, arthroscopic labral repair has become increasingly reliable, with improvement in techniques that utilize better suture anchors and experience with concomitant capsulorrhaphy.
Although some studies report similar results with arthroscopic and open labral repair [5, 6], other studies document superior results with open Bankart repair. [7, 8] An open Bankart procedure is generally suitable for patients with multiple episodes of instability, pathologic capsular laxity, and significant glenoid bone loss less than 20%. These factors are even more critical in young patients playing contact sports.
The Latarjet coracoid transfer is an option for patients considered at high risk for failure with arthroscopic repair. The open Bankart is an alternative for these patients if they do not have the degree of bone loss that would require a Latarjet.
The Latarjet procedure involves transferring a segment of the coracoid process, along with its attached musculature, to the anterior margin of the glenoid, where it acts as a strut to prevent subsequent dislocation of the shoulder.  This procedure is particularly effective for patients with significant bone loss or fracture of the glenoid. However, complications with the bone graft and hardware can occur.
An alternative to the Latarjet is the Bristow, a similar procedure in which the transferred coracoid fragment is smaller and is fixed with a single screw to the anterior aspect of the scapular neck through a transverse opening in the subscapularis muscle. 
Advantages of the Bristow procedure include elimination of the need to take down the subscapularis, provision of a sling effect due to the transferred portion of the conjoint tendon, and ability of the surgeon to perform a labral repair with inferior shift. The Bristow would be a reasonable alternative to the open Bankart repair, therefore, in patients with minimal bone loss.
More recently, there has been a move toward utilizing the Bristow procedure in conjunction with arthroscopic Bankart repair in contact athletes. Tasaki et al  reported favorable outcomes in 38 rugby players, with no recurrent dislocations noted at a mean follow-up of 30.5 months. However, they also found that the ability to perform certain sports-specific maneuvers (such as hand-off and tackle) remained impaired in some patients postoperatively. 
It has been noted that patients with a history of recurrent dislocations prior to surgery are at an increased risk of failed arthroscopic shoulder stabilization compared with first-time dislocators.  Moreover, patients with a history of traumatic recurrent anterior shoulder instability who have bone loss or shoulder hyperlaxity are at risk for recurrent instability after arthroscopic Bankart repair. 
Open Bankart repair has been found to produce favorable outcomes in patients who present with recurrent anterior shoulder instability after failed arthroscopic stabilization. [14, 15] Pagnani et al  noted that football players undergoing open stabilization procedures appear to have superior postoperative stability when compared with the reported outcomes of arthroscopic stabilization in this population. However, surgeons must consider the possibility of postoperative loss of range of motion when performing an open repair. 
As highlighted in this case presentation, open Bankart repair is still a viable and effective procedure for certain patients with recurrent anterior shoulder instability.
William Emper, MD, is Clinical Associate Professor, Department of Orthopaedic Surgery, The Rothman Institute, The Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania. He is also Chief of Orthopaedics at Bryn Mawr Hospital, Bryn Mawr, Pennsylvania, and Team Physician for Villanova University. Zaira Chaudhry, MPH, is a Research Fellow at The Rothman Institute, Philadelphia, Pennsylvania.
Sports Medicine Section Editor, Rothman Institute Grand Rounds
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