Variability of Reporting Recurrence After Arthroscopic Bankart Repair: A Call for a Standardized Study Design

Abstract

Background: High recurrence rates have been reported after anterior shoulder dislocations, regardless of the treatment utilized. However, the definition of recurrent instability has been inconsistent, making a comparison between studies difficult. Purpose: To report on the nature with which the rate of recurrent instability is reported after arthroscopic Bankart repair, across all levels of evidence, and to analyze factors that may affect the reported rate of recurrence. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of the literature was performed by searching PubMed, the Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov for studies published within the dates of January 2008 and September 2018. Studies in English that reported on the recurrence of instability after arthroscopic Bankart repair for anterior shoulder instability were considered for inclusion in this review. A meta-regression was performed to test for a linear association between the reported recurrence rate and several continuous covariates, including mean age at surgery, mean length of follow-up, attrition rate (loss to follow-up percentage), and percentage of male patients. Results: A trim-and-fill meta-analysis yielded an estimated overall recurrence rate of 17.4% (95% CI, 14.3%-20.9%). There was a significant difference in the recurrence rate depending on the level of evidence (Q(3) = 10.98; P = .012). Significant associations were found with the recurrence rate through the meta-regression, including a negative association with mean age ( P = .009), a positive association with mean follow-up time ( P = .002), and a positive association with attrition rate ( P = .035). Conclusion: A call for standardization is necessary for reporting outcomes of anterior instability after arthroscopic Bankart repair, especially with regard to the reporting of recurrence/failure rates, with careful consideration of the effects that may occur from patient demographics and study design. With no current recommendations for deeming failure, we suggest that all forms of instability be accounted for when determining a failed treatment procedure, with future studies placing an emphasis on greater control of the study design.

High Variability of the Definition of Recurrent Glenohumeral Instability: An Analysis of the Current Literature by a Systematic Review

“…He introduced the frequency, etiology, direction, and severity system for describing instability. Kennedy et al 8 has described that there is a wide variety of definitions of recurrence in the literature and that the recurrence rates vary according to level of evidence, age, follow-up time, and attrition rate. Although Kennedy et al 8 have noticed that there are many different definitions used in the literature, it is still unclear how many studies did not define these definitions.…”

Large Drill Holes Are Still Present in the Long Term After Arthroscopic Bankart Repair With Absorbable Tacks: An 18-Year Randomized Prospective Study

“…In a recent systematic review, Kennedy et al 18 reported a Bankart repair failure rate of 17.4% with a positive association to length of follow-up and the number of patients lost to follow-up. This finding is in line with the results of the present study.…”

“…In line with this, Marchant et al 22 showed that among the 3 imaging modalities, CT had a better inter-and intraobserver validity in describing bone tunnel widening after anterior cruciate ligament reconstruction. In a recent systematic review, Kennedy et al 18 reported a Bankart repair failure rate of 17.4% with a positive association to length of follow-up and the number of patients lost to follow-up. This finding is in line with the results of the present study.…”

Editorial Commentary: Evidence to Support Surgical Intervention for First-Time Shoulder Instability: Stabilize Them Early!

“…However, it may be difficult to justify early surgery in certain patient populations. In another systematic review, Kennedy et al 24 found an overall recurrence rate of 17.4% following arthroscopic Bankart repair, which suggests that postoperative results following repeated instability events are inferior compared with early stabilization. The lower non-recurrence complication rate of 1.6% reported by Hurley et al adds to the argument that young, active patients should be recommended surgical stabilization following a primary anterior shoulder dislocation.…”

“…In this regard, we, as surgeons should follow our outcomes with a keen sense of recurrence, as either recurrent dislocation or recurrent subluxation and provide both to allow the reader important outcomes information. 24 More prospective studies with robust study design and sufficient power are needed to investigate whether the indication for surgical stabilization following the first instability event should be expanded to other patient groups. We need to standardize how recurrence of instability is reported, and we propose that recurrence include dislocation, subluxation, feeling of apprehension, and painful, unstable shoulders.…”