Opinion editorial—soft tissue bankart: Still the gold standard

ABOUT THE EXPERT

Hiroyuki Sugaya, MD, served as Chairman of Sports Medicine & Joint Center in Funabashi Orthopaedic Hospital for 18 years. Dr. Sugaya opened Tokyo Sports & Orthopaedic Clinic in Tokyo in August 2020 to further pursue his unbounded clinical interest in the field of shoulder and elbow surgery and to dedicate himself to the education of young surgeons and therapists.

Since Prof. Masaki Watanabe developed the #21 arthroscope in 1959, arthroscopy spread out mainly in North America after Robert W. Jackson (who learned this technology from Prof. Watanabe in 1964) introduced this technology there. In the 1960s and 1970s, arthroscopy was used mainly in the knee, but in early 1980s it was applied to the shoulder and spread out worldwide.

I performed my first arthroscopic shoulder stabilization in 1995, using the Caspari transglenoid suture repair. Shortly after that I performed my first suture anchor repair in 1997 ( Table 45.1 ). Of course, as is usual with other shoulder specialists in early times, I experienced many failures after arthroscopic soft tissue stabilization. However, I have modified my techniques by contemplating the cause of failures in each case. By 2005, I had defined much of my current style of arthroscopic shoulder stabilization and felt quite happy with the outcomes with remarkably reduced failure rates (see Table 45.1 ). ^, In the meantime, since Latarjet introduced the original procedure in 1954, ^, open or arthroscopic Latarjet was introduced ^, and has become for many the primary method of stabilization in shoulders with severe glenoid bone loss. However, recently there has become a trend to perform it even to the shoulders without bone loss despite the invasiveness of this nonanatomic procedure.

TABLE 45.1

My Personal History of Shoulder Stabilization

1997	All-arthroscopic Bankart repair
2000	Arthroscopic bony Bankart repair
2002	Rotator interval closure incorporating subscapularis tendon as an augmentation ^a
2003	Cartilage removal at anteroinferior glenoid face ^b
2004	Use of high-strength sutures
2005	Hill-Sachs remplissage for revision or large lesion
2006	Arthroscopic iliac crest grafting with capsulolabral reconstruction for severe bone loss
2010	Arthroscopic Latarjet for severe bone loss with poor capsule shoulders
2012	Hill-Sachs remplissage for teens as augmentation

a Recurrence dramatically decreased after adding this augmentation.

b See Fig. 45.3 .

Here, I describe my five important key breakthroughs together with my personal history and evolution of the arthroscopic soft tissue Bankart procedure.

Breakthrough #1: I do all-arthroscopic repairs for instability

Since shoulder arthroscopy was introduced in Japan by Dr. Minoru Yoneda in the late 1980s, many shoulder surgeons have been interested in trying arthroscopic labrum repair. Many tried arthroscopic Bankart repair and experienced failures. Then, in the late 1990s, it was suggested that we should limit the indications for arthroscopic Bankart repair to patients who had good ligament quality and noncollision/contact athletes. However, at the annual meeting of Japan Shoulder Society in 1998 I declared that “I do all-arthroscopic repairs for instability.” Since then, I started to develop ways to repair shoulders arthroscopically when there seemed to be so-called contraindications for the arthroscopic approach.

In those days, there were discussions about glenoid morphologies, such as glenoid rim lesions by Bigliani ; however, no one demonstrated the exact shape and prevalence of these in recurrent shoulder instability. I thought that if we were able to assess the exact glenoid morphology preoperatively, this could be a great first step for surgeons to perform arthroscopic shoulder stabilization. Then, I asked radiologic technicians to manually remove the humeral head from the computed tomography (CT) scan images so that we could have a clear view of the glenoid (CT scan at that time was not the fancy multislice system we have now). Using this approach, I investigated 100 chronic instability cases and categorized three subtypes (bony Bankart, erosion, and normal) and the prevalence in each subtype ( Fig. 45.1 ).

Furthermore, to elucidate the significance of these morphologic changes, I investigated another 200 unilateral chronic instability cases to compare glenoid morphology and constitutional joint laxity on the affected side with that on the contralateral normal side. I found that the bony Bankart lesion tends to occur in tight male shoulders with high-energy injuries, resulting in recurrent subluxation. Glenoid erosion had a predominance in females with intermediate laxity, resulting in recurrent dislocation ( Fig. 45.2 ). These findings greatly help surgeons in their decision making prior to surgical stabilization.

Breakthrough #2: Ligament retensioning

Recently, several authors reported extremely poor long-term outcomes after soft tissue Bankart repair. ^, Therefore many surgeons deemed soft tissue Bankart to be an unreliable procedure in the active patients (e.g., collision/contact athletes). Castagna et al. stated that, although the recurrence rate increased with time and rose up to 23% at minimum 10-year follow-up, 84% of patients were satisfied with the surgery at the final follow-up. On the other hand, according to van der Linde et al., 35% reported recurrence at 8 to 10 years after surgery; they stated that the use of fewer than three anchors is a possible cause of recurrence. Based on their findings, inadequate ligament retensioning seems to be one of the most frequent causes of failures after arthroscopic soft tissue stabilization.

When I revised shoulders that had undergone soft tissue stabilization using suture anchors, I realized that the ligament release was inadequate by looking at the anchor position and the number of anchor holes in three-dimensional CT ( Fig. 45.3 ). I believe that Bankart repair is not a simple anterior labrum repair but the procedure to reconstruct entire inferior glenohumeral ligament (IGHL) integrity; therefore, even if Bankart lesion is present only at the 2 to 5 o’clock position (right shoulder), the surgeon needs to release up to the 7 or 7:30 o’clock position and completely free up the capsule-labrum complex and remove the cartilage at the face of anteroinferior glenoid to maximize tissue healing to the glenoid. Then, Bankart repair is performed using at least four anchors to provide adequate tension to the entire IGHL ( Fig. 45.3 ). ^, ^,