We have performed arthroscopic Bankart procedures using absorbable or metallic suture anchors for traumatic anterior shoulder instability for over a decade. This article describes the frequency, pathology, and therapeutic results of patients treated for superior labrum anterior and posterior (SLAP) lesions concomitant with Bankart lesions.
Twenty patients (Group A) had a mean age of 33.8 years at the time of surgery. On arthroscopic findings, SLAP lesions were classified type 2 in 15 patients and type 4 in 5, based on Snyder’s criteria. In addition, intra-articular free bodies were present in 2 SLAP lesions, and a capsular tear was present in 1. We performed debridement (Group A1) or reattachment (Group A2) to the superior glenoid edge of these lesions, considering whether they communicated to Bankart lesions. The therapeutic results were evaluated according to the Japanese Orthopaedic Association (JOA) score and Japan Shoulder Society (JSS) shoulder instability score. Mean JOA and JSS shoulder instability scores were 95.1 and 90.8 points, respectively. All Group A patients remained pain free, and no instability recurred in any patient. Meanwhile, mean JSS shoulder instability function and range of motion scores were 18.9 and 15.1 points, respectively, in Group A1, and 17.5 and 10.1 points, respectively, in Group A2. A significant correlation in range of motion was observed in Groups A1 and A2 (P=.04). Regarding postoperative limitation in external rotation with the arm at the side, the difference in range from that on the healthy side was 9.8° in Group A (7.0° in Group A1 and 12.6° in Group A2).
When SLAP lesions communicated to Bankart lesions, we had satisfactory results without SLAP repair; therefore, unnecessary repairs for the concomitant pathology should be avoided, and different postoperative care should be performed for patients with Bankart repair with reattachment of a SLAP lesion.
The inferior glenohumeral ligament, anterior glenoid labrum damage, and bony lesions of the anteroinferior margin of the glenoid play an important role in traumatic anterior shoulder instability. The pathology of the glenoid labrum–anterior band of the inferior glenohumeral ligament complex has been recognized in recent years as important. The frequency of Bankart lesions as intra-articular lesions in traumatic anterior shoulder instability has been reported in the literature.1,2
We have performed arthroscopic Bankart procedures using absorbable or metallic suture anchors for traumatic anterior shoulder instability since 1998. The avulsion of the anteroinferior capsulolabral complex from the glenoid rim (soft tissue Bankart lesion) or bony Bankart lesion was noted in all patients (N=82) on preoperative examinations or arthroscopic findings. However, some patients showed superior labrum anterior and posterior (SLAP) lesions concomitant with Bankart lesions. The purpose of this study was to investigate the frequency, pathology, and therapeutic results of patients treated for SLAP lesions concomitant with Bankart lesions.
Materials and Methods
Eighty-two patients underwent an arthroscopic Bankart procedure performed with suture anchors by the author. Sixty-five men and 17 women had chronic isolated traumatic anterior shoulder instability and were followed up for >1 year postoperatively. Mean patient age at the time of surgery was 30.9 years (range, 16-70 years). Soft tissue or bony Bankart lesions were noted in all patients during arthroscopic surgery, and concomitant intra-articular lesions were present in 27 patients. Of these 27 patients, concomitant SLAP lesions were noted in 20. These 20 patients (Group A) were included in this study.
Group A comprised 16 men and 4 women, and mean patient age at the time of surgery was 33.8 years (range, 16-63 years). The right side was affected in 13 patients (and was the dominant side in 12), and the left side was affected in 7 patients (and was the dominant side in 1). Eighteen of the 20 patients had participated in some sporting activity before the injury: 3 were playing basketball, 2 were playing baseball, 2 were dancing, 2 were playing rugby, 2 were snowboarding, 1 was playing football, 1 was playing soccer, 1 was playing volleyball, 1 was playing golf, 1 was riding horseback, 1 was swimming, and 1 was practicing judo.
Two patients had recurrent dislocation (4 and 6 times, respectively) but no subsequent signs of subluxation, 8 patients had recurrent subluxation (>5 times) but no verified dislocation, and 10 patients with a mix of dislocation and subluxation had an episode of instability preoperatively. An episode of instability in which self-reduction was possible was defined as also having subluxation. All patients had a positive sign in the anterior apprehension test, in which the shoulder was in 90° abduction, and in the relocation test conducted during the physical examination, but none showed multidirectional instability. The diagnostic imaging for the assessment of intra-articular lesions included arthrography, computed tomography (CT) after arthrography, magnetic resonance imaging (MRI) after arthrography, and 3-dimensional CT. Arthrography was performed using a 12 mL mixture of 6 mL iotrolan and 6 mL 1% lidocaine.
On arthroscopic findings, SLAP lesions were classified type 2 in 15 patients and type 4 in 5, based on the criteria of Snyder et al.3 In addition, intra-articular free bodies were present in 2 SLAP lesions, and a capsular tear was present in 1.
Arthroscopic Bankart procedures using suture anchors were performed in all patients. The patients were in the beach chair position, and 3 portals were required: a standard posterior viewing portal, an anterosuperior portal, and an anterior portal. Suture anchors were placed at 5 o’clock, 4 o’clock, and 3 o’clock at the anterior articular edge (right side), and these sutures were tied as the labrum mobilized onto the articular edge with a inferior capsular shift.
When SLAP lesions communicated to Bankart lesions (Figure 1), debridement of the superior labrum and Bankart repair without reattachment of the SLAP lesion were performed. This was performed in 10 patients (Group A1): 9 with type 2 lesions and 1 with a type 4 lesion. If there was no communication between the Bankart lesion and SLAP lesion (Figure 2), these lesions were reattached to the superior glenoid, and Bankart repair was performed. This was performed in 10 patients (Group A2): 6 with type 2 lesions and 4 with type 4 lesions (Figure 3). The capsular tears were sutured (Figure 4), and intra-articular free bodies were removed. Metallic and absorbable suture anchors were used in 6 and 14 patients, respectively. The rotator interval was not closed in any case.
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Figure 4: A 21-year-old baseball player. On arthroscopic findings (left shoulder in posterior view), a Bankart lesion (A) complicated with a capsular tear (B) was noted. The labrum detached from 7 o’clock to 10 o’clock and the capsular tear was a midsubstance tear located from rotator interval to superior edge of the anterior band of the inferior glenohumeral ligament.
Postoperative care consisted of immobilization with a Désault’s bandage for approximately 3 weeks. Forward elevation by passive movement in the supine position and pendulum exercises were prescribed from 4 weeks postoperatively. After confirming a forward elevation >160° at 7 weeks, muscle-strengthening exercises of the infraspinatus and subscapularis muscles were initiated. At 10 weeks postoperatively, muscle-strengthening exercises of the supraspinatus and deltoid muscles were prescribed. Patients were permitted to return to sports activities approximately 6 months postoperatively.
The duration of postoperative follow-up ranged from 1 year and 2 months to 4 years and 1 month (mean, 2 years and 3 months). The therapeutic results were evaluated according to the Japanese Orthopaedic Association (JOA) score and Japan Shoulder Society (JSS) shoulder instability score. Fifty-five patients (Group B) with only Bankart lesions were studied as a comparison group. Group B comprised 43 men and 12 women with an average patient age of 31 years at the time of surgery (range, 16-70 years). Eighteen patients had recurrent dislocation (from 2 to 8 times) but no subsequent signs of subluxation, 7 patients had recurrent subluxation (>3 times) but no verified dislocation, and 30 patients had a mix of dislocation and subluxation with an episode of instability preoperatively.
Statistical analyses were evaluated by Welch’s t test or Fisher’s exact probability test (level of significance >.05).
Three of the 20 patients in Group A experienced pain preoperatively; 1 patient in Group A1 had a type 4 SLAP lesion with intra-articular free bodies, and 2 patients in Group A2 had type 2 SLAP lesions. The other 17 patients reported no pain, but 8 of 20 patients were positive on the crank test, and no patient was positive on the biceps load test II. On preoperative assessment of shoulder joint function, the mean JOA and JSS shoulder instability scores were 82.1 points (Group A1, 82.3; Group A2, 81.9) and 61.5 points (Group A1, 62.8; Group A2, 60.2), respectively, whereas they were 84.7 and 63.6 points, respectively, in Group B patients. No significant correlation was found between shoulder joint function and concomitant pathologies.
Therapeutic results are shown in the Table. Mean JOA and JSS shoulder instability scores were 95.1 and 90.8, respectively, in Group A, and 97.2 and 96.1, respectively, in Group B, showing satisfactory outcomes. All patients in Groups A and B remained pain free, but subluxation recurred in 1 patient in Group B during tennis practice 1 year postoperatively. This patient had a dislocated metallic screw in the glenohumeral joint; the other 81 cases had no anchor screw complications. Range of motion tended to decrease in Group A rather than in Group B. The JOA score was 26.3 points in Group A and 28.9 points in Group B, while the JSS shoulder instability score was 12.6 in Group A and 17.2 points in Group B, but the differences were not significant (P=.11). Meanwhile, on detailed analysis of Groups A1 and A2, the mean function and range of motion scores were 18.9 and 15.1 points, respectively, in Group A1, and 17.5 and 10.1 points, respectively, in Group A2. A significant correlation was found in the range of motion between Groups A1 and A2 (P=.04). Regarding postoperative limitation in external rotation with the arm at the side, the difference in the range from that on the healthy side was 9.8° in Group A (Group A1, 7.0°; Group A2, 12.6°), but only 5.2° in Group B.
Various factors may affect the mechanism of static stabilization of the glenohumeral joint: articular congruency (the relationship between the angle of inclination of the glenoid or the angle of retroversion of the humeral head), negative intra-articular pressure, development of an adhesive joint, suppression by the ligament and joint capsule (glenohumeral ligaments or coracohumeral ligament), glenoid labrum, and osseous elements. However, the incidence of Bankart lesions as intra-articular lesions in traumatic anterior shoulder instability has been reported to be 83.5% by Yiannakopoulos et al2 and 100% by Takase et al.4 However, if only the Bankart lesion is repaired despite other intra-articular lesions being present, anterior shoulder instability may remain in some cases.5
Regarding the injury mechanism of SLAP lesions, Snyder et al3 reported that the force of pushing up the glenoid by the humeral head on touching the ground with the hand in abduction of the shoulder joint caused type 1 or 2 SLAP lesions, and the addition of external rotation to this axially compressed condition led to type 3 or 4 lesions complicated by anterior instability. In some cases, recurrent dislocation or subluxation and traction by the tendon of the long head of the biceps brachii may lead to a SLAP lesion concomitant with a Bankart lesion. McMahon et al6 studied whether the severity of simulated type 2 SLAP lesion affected glenohumeral joint translations and reported that glenohumeral joint translation was increased, regardless of severity, after simulation of a type 2 SLAP lesion. During stabilizing surgical interventions, passive stabilizers injured in a type 2 SLAP lesion should be considered, as well as dynamic activity in the tendon of the long head of the biceps brachii.
Taylor and Arciero7 reported on a prospective study of patients younger than 24 years with first-time traumatic anterior shoulder dislocations. Sixty-one of 63 patients had a Bankart lesion with no gross evidence of intracapsular injury. There were 6 SLAP lesions, and 2 with detachment of the biceps tendon.
In 1994, Warner et al8 reported 7 cases of SLAP lesion associated with Bankart lesion, and all were type 2. They underwent arthroscopic repair of the entire anterior-inferior-superior-posterior labral detachment using a fixation device. Five of 7 patients had no pain, full range of motion, and a full premorbid activity level.
In 2007, Yiannakopoulos et al2 reported on intra-articular lesions in a series of 127 patients with acute (23 patients) and chronic (104 patients) traumatic anterior shoulder instability. Bankart lesions were noted in 119 patients (18 acute and 101 chronic), and SLAP lesions were noted in 26 patients. Of these 26 patients, 3 had type 1 acute lesions, 2 had type 2 acute lesions, 4 had type 1 chronic lesions, 13 had type 2 chronic lesions, 3 had type 3 chronic lesions, and 1 had a type 4 chronic lesion. The authors concluded that secondary intra-articular lesions are more frequent in patients with chronic cases, probably as a result of repeated dislocation or subluxation episodes.
Arrigoni et al9 studied intra-articular pathology in patients undergoing shoulder arthroscopy immediately before modified Latarjet reconstruction for recurrent anterior instability with bone deficiency. Associated pathologic lesions were identified in 24 of 33 patients, and 21 type 2 SLAP lesions were identified. The authors recommended that arthroscopic examination before modified Latarjet reconstruction allows the surgeon to address associated pathologic entities.
In 2007, Antonio et al10 reported intra-articular lesions and age-related differences after first-time shoulder dislocation by magnetic resonance arthrography in 66 patients. Forty-eight patients showed bony or soft tissue Bankart lesions, and SLAP lesions were identified in 9 patients (14%), 6 of whom were younger than 29 years and 3 of whom were older than 30 years.
In the present study, soft tissue or bony Bankart lesions were noted in all 82 patients, but other intra-articular lesions were also present in approximately 32.9% of patients (SLAP lesion in 20, capsular rupture in 5, and intra-articular free body in 5, including overlapping injuries). For SLAP lesions, only debridement or reattachment to the superior glenoid was performed, considering whether these lesions communicated to Bankart lesions. In other words, when these lesions communicated to Bankart lesions, the enlargement on detachment of the anterior labrum from anterior margin of the glenoid, which occurred from repeated dislocation or subluxation, may have led to the SLAP lesion; in those cases, only the Bankart lesions were repaired. The therapeutic results of patients without reattachment of a SLAP lesion showed no pain and instability, and a significant difference in the restriction of external rotation compared to the patients with reattachment of a SLAP lesion.
Arthroscopic reconstruction for traumatic anterior shoulder instability has become more common during the past decade. Compared with open reconstruction, arthroscopic techniques allow for improved diagnosis of numerous intra-articular lesions. The surgeon must be prepared to address numerous conditions beyond a Bankart lesion, especially those involving capsular tears, rotator cuff lesions, and SLAP lesions. Complications other than Bankart lesions should also be repaired in primary surgery, but capsular tension may be increased compared to that after the normal Bankart procedure, and limitation in the range of motion may remain. Therefore, unnecessary repair to the concomitant pathology should be avoided, or that we should perform the different postoperative care for these patients with Bankart repair with reattachment of SLAP lesion.
In traumatic anterior shoulder instability, when intra-articular lesions were present in addition to a Bankart lesion, although no apparent difference was noted in the recurrence of instability, the outcome of the range of motion tended to be poorer. therefore, unnecessary repairs for the concomitant pathology should be avoided, and different postoperative care should be performed for patients with Bankart repair with reattachment of a SLAP lesion.
- Mahirogullari M, Kuskucu M, Solakoglu C, et al. Comparison of outcomes of two different surgeries in regarding to complications for chronic anterior shoulder instability. Arch Orthop Trauma Surg. 2006; 126(10):674-679.
- Yiannakopoulos CK, Mataragas E, Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthroscopy. 2007; 23(9):985-990.
- Snyder SJ, Karzel RP, Del Pizzo W, Ferkel RD, Friedman MJ. SLAP lesions of the shoulder. Arthroscopy. 1990; 6(4):274-279.
- Takase K, Yamamoto K. Intraarticular lesions in traumatic anterior shoulder instability: a study based on the results of diagnostic imaging. Acta Orthop. 2005; 76(6):854-857.
- Tauber M, Resch H, Forstner R, Raffl M, Schauer J. Reasons for failure after surgical repair of anterior shoulder instability. J Shoulder Elbow Surg. 2004; 13(3):279-285.
- McMahon PJ, Burkart A, Musahl V, Debski RE. Glenohumeral translations are increased after a type II superior labrum anterior-posterior lesion: a cadaveric study of severity of passive stabilizer injury. J Shoulder Elbow Surg. 2004; 13(1):39-44.
- Taylor DC, Arciero RA. Pathologic changes associated with shoulder dislocations. Arthroscopic and physical examination findings in first-time, traumatic anterior dislocations. Am J Sports Med. 1997; 25(3):306-311.
- Warner JJ, Kann S, Marks P. Arthroscopic repair of combined Bankart and superior labral detachment anterior and posterior lesions: technique and preliminary results. Arthroscopy. 1994; 10(4):383-391.
- Arrigoni P, Huberty D, Brady PC, Weber IC, Burkhart SS. The value of arthroscopy before an open modified latarjet reconstruction. Arthroscopy. 2008; 24(5):514-519.
- Antonio GE, Griffith JF, Yu AB, Yung PS, Chan KM, Ahuja AT. First-time shoulder dislocation: high prevalence of labral injury and age-related differences revealed by MR arthrography. J Magn Reson Imaging. 2007; 26(4):983-991.
Dr Takase is from the Department of Orthopedic Surgery, Tokyo Medical University, Tokyo, Japan.
Dr Takase has no relevant financial relationships to disclose.
Correspondence should be addressed to: Katsumi Takase, MD, Department of Orthopedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku Shinjuku-ku, Tokyo, Japan 160-0023.