IRCCS CLINICAL INSTITUTE HUMANITAS Milano - Italy Shoulder and Elbow Department Director: A. Castagna Scientific Director: M. Randelli

Arthroscopic Bankart suture anchor repair: radiological and clinical outcome at minimum 10 years F.U. SECEC- ASES Europe- USA Travelling Fellowship 2008 N. Markopoulos, G. Delle Rose, M. Conti, E. Papadakou, A. Castagna

“Arthroscopic stabilisation using suture anchors seems to be the most effective technique for Bankart repair with similar rate of failure to open stabilisation”. Boileau P. JBJS Br, 2007 Literature

Literature Suture Anchors Recurrence Bacilla, 1997; F.U. 18m 7,5% Burkhart, 2000; F.U. 27m 10,8% Gartsman, 2000; F.U. 33m 8% Kim, 2003; F.U. 44m 4% Tauro, 2002; F.U. 36m 5,2% Takagi, 2004; F.U. 42m 9,5% Garofalo,2005; F.U. 46m 10% Romeo, 2005; F.U. 37m 11% Marqardt, 2006; F.U. 46m 7,5% Larrain, 2006; F.U. 70m 8% Short and mid term follow up

Literature Degenerative changes after Bankart repair Kartus, Resch, JBJS Am 2007; evidence of significant arthritic changes at 7 to 10 yrs F.U. using absorbable tacks (extra- articular repair) in a study of 81 patients Few studies about degenerative changes after arthroscopic Bankart repair Rowe 1978 Hawkins 1990 Rosenberg 1995 Chapnikoff 2000 Kartus 2006 Open technique

Purpose of the study A long term (minimum 10 years) evaluation of the clinical and radiological results after arthroscopic Bankart repair using suture anchors with particular concern to the recurrence and the arthritis Assessment of negative predicting factors

Materials and methods From 1995 to 1997, 47 consecutive patients (48 shoulders) with traumatic instability were treated arthroscopically Excluded cases with multidirectional instability or with associated RC tears

Materials and methods Study of 30 patients / 31 shoulders (66% of all cases) Same surgeon, same technique Age yrs (average 26,1yrs) 26 M and 4 F Mean F.U.: 11,2yrs (9,8- 12,9yrs)

Materials and methods Clinical evaluation (independent physician) –Rowe,UCLA, SST rating scores –ROM, return to sports and working activity Radiological assessment of degenerative changes according to the classification of Samilson- Prieto Patients satisfaction

Materials and methods Standard posterior portal Antero- superior portal Anterior midglenoid portal Suture anchors 2 to 5; mean value 2,4 (mini-Revo; Linvatec) Surgical Technique

Postoperative treatment Arm in a sling at 20° of abduction for 4 weeks Early mobilization of the elbow and hand At 2 weeks progressive passive mobilization of the shoulder with ER1 at 0° Active mobilization and resistence exercises at 6 to 8 weeks postop Return to sports activity at 5 months after the operation

Results Recurrence in 6 patients Subluxation in 1 patient Patients satisfaction 83% One patients has undergone a revision arthroscopy Total recurrence rate 22,5%

Results 7 patients experienced shoulder instability; although 2 of them had a new clinically relevant shoulder injury (atraumatic recurrences 16 %). 3 of the patients with recurrence, were satisfied and able to return to their previous activity level (two patients with a recurrence after 6 yrs experienced some apprehention, one had a subluxation and now practices snow board in a competitive level). The results deteriorate during time: three (out of seven) recurrences occured after 6 yrs. Critical evaluation of these data

Results Recurrence Group: Six out of 7 patients with recurrence were competitive or overhead athletes (85,7%), Non Recurrence Group: Nine out of 24 patients (37,5%) were competitive/overhead athletes 36% of recurrence in the athletes vs 15% in the other group Critical evaluation of these data

Results Clinical outcomes UCLA 21,8 32,1 SST 9 11,2 Return to sports activities (same level) 70 % Return to work 96,6 % In 83,4% of all cases no loss of ROM (five patients with limitation of the ER2 < 15°) Rowe excellent 58% good 19,3% fair 3,3% poor 19,4%

Results Radiological outcomes No arthrosis (grade 1) 61 % Mild (grade 2) 29 % Moderate (grade 3) 10 % Severe (grade 4) 0 % No evidence of suture anchor loosening or osteolysis

Discussion Results showed a relative high rate of recurrence instability compared to other studies but we think that a long follow up is necessary to assess “true” outcomes (non traumatic recurrence at 5 yrs = 9,6%). Mild degenerative changes were noted at 39% of all cases but did not influence the final result regarding the % of recurrence, ROM, function and satisfaction of the patient.

Discussion We didn’t find any correlation between recurrence and number of preoperative dislocations, age or number of anchors used. Involvement in competitive or overhead sports might have been recurrence risk factor after arthroscopic Bankart repair.

Conclusions Good clinical and subjective outcomes at a 5 yrs follow up with deterioration at a longer period. Better results in non competitive athletes or in those who are not involved in overhead sports. Radiologic evidence of arthritis but of a mild entity without consequences on the result.

Conclusions Further studies must be undertaken to assess the results in terms of recurrence, ROM and degenerative changes observed in our latest series using new devices with a better experience.

Grazie