When to Abandon the Arthroscopic Bankart Repair: A Systematic Review

Abstract

Context: Bone loss is a major factor in determining surgical choice in patients with anterior glenohumeral instability. Although bone loss has been described, there is no consensus on glenoid, humeral head, and bipolar bone loss limits for which arthroscopic-only management with Bankart repair can be performed. Objective: To provide guidelines for selecting a more complex repair or reconstruction (in lieu of arthroscopic-only Bankart repair) in the setting of glenohumeral instability based on available literature. Data Sources: An electronic search of the literature for the period from 2000 to 2019 was performed using PubMed (MEDLINE). Study Selection: Studies were included if they quantified bone loss (humeral head or glenoid) in the setting of anterior instability treated with arthroscopic Bankart repair. Study Design: Systematic review. Level of Evidence: Level 4. Data Extraction: Study design, level of evidence, patient demographics, follow-up, recurrence rates, and measures of bone loss (glenoid, humeral head, bipolar). Results: A total of 14 studies met the inclusion criteria. Of these, 10 measured glenoid bone loss, 5 measured humeral head bone loss, and 2 measured “tracking” without explicit measurement of humeral head bone loss. Measurement techniques for glenoid and humeral head bone loss varied widely. Recommendations for maximum glenoid bone loss for arthroscopic repair were largely <15% of glenoid width in recent studies. Recommendations regarding humeral head loss were more variable (many authors providing only qualitative descriptions) with increasing attention on glenohumeral tracking. Conclusion: It is essential that a standardized method of glenoid and humeral head bone loss measurements be performed preoperatively to assess which patients will have successful stabilization after arthroscopic Bankart repair. Glenoid bone loss should be <15%, and humeral head lesions should be “on track” if an arthroscopic-only Bankart is planned. If there is greater bone loss, adjunct or open procedures should be performed.

The 50 Most-Cited Papers on Bankart Lesions

“…The newest analysis of this issue focuses on both GBL and humeral head bone loss (bipolar lesions); however, there still remains significant debate over the treatment of borderline bipolar lesions with respect to remplissage versus bony augmentation. 63 …”

“…The newest analysis of this issue focuses on both GBL and humeral head bone loss (bipolar lesions); however, there still remains significant debate over the treatment of borderline bipolar lesions with respect to remplissage versus bony augmentation. 63 At times throughout postgraduate training, it may be difficult and time-consuming for trainees to search through the vast peer-reviewed literature to find influential manuscripts. One of the aims of this current project was to provide a concise, high-impact reading list to residents, fellows, and attending physicians on the topic of Bankart lesions.…”

Editorial Commentary: Surgical Treatment of Shoulder Instability With Subcritical Glenoid Bone Loss Requires Innovation: Bankart May Risk Significant Recurrence and Latarjet May Risk Significant Complications

“…I can offer this patient the "safest" procedure (arthroscopic Bankart repair), with perhaps the greatest rate of failure and risk of needing further surgery. 1,2 Or, I can offer the most successful procedure for avoiding recurrence (Latarjet), which comes with potentially high complication rates of up to 20%, a steep learning curve, risk of permanent nerve injury up to 15%, and substantial risk of subscapularis deficit. [3][4][5] The other established…”

Editorial Commentary: A Consensus of Experts Complements the Clinical Evidence on Diagnosis and Treatment of Anterior Glenohumeral Instability

“…8 Despite the refinement of arthroscopic stabilization techniques, some surgeons continue to advocate open Bankart repair in collision athletes, including those with intermediate degrees of bone loss. 9,10 Despite these graduated advancements, several controversies remain that are related to the diagnosis and treatment of anterior glenohumeral instability. The thresholds for subcritical glenoid and humeral bone loss for arthroscopic Bankart repair have been evolving over time, and these thresholds may depend on patient age, activity level, and other factors.…”