Arthroscopic Bankart repair in patients aged 30 years and older: a systematic review

Introduction

Recurrent shoulder instability after anterior dislocation is common amongst young individuals, with recurrence rates reported from 40% to as high as 90% (1,2). Thus, surgical stabilization is recommended to this cohort and has been shown to dramatically decrease the risk of subsequent instability events with good clinical outcomes (3). As the population ages, the risk of shoulder dislocation and subsequent recurrent instability generally decreases and thus the importance of surgical stabilization becomes less clear (1,4,5). However, with increasing longevity, middle-aged patients are participating in leisure activities that place them at risk of high-energy injuries such as shoulder dislocations (1,6,7). In fact, middle-aged and elderly patients are increasingly experiencing anterior shoulder dislocations, with patients aged above 60 years old accounting for 20% of all dislocations (1,4,8,9). Unlike younger patients who primarily present with capsulolabral lesions, middle-aged patients have an additional risk of associated lesions such as nerve injury, rotator cuff tear and greater tuberosity fracture (1).

Patients aged 30 years or younger have a higher frequency of recurrent anterior shoulder instability (2,4,10-12). Age has been identified as the greatest risk factor for recurrence after arthroscopic Bankart repair, with patients less than 20 experiencing the highest rates of instability post-operatively (4,13). A systematic review identified that pediatric patients (≤19 years old) undergoing arthroscopic Bankart repair were at high risk of recurrent instability despite surgical stabilization (24%) (3). Meanwhile, recurrent anterior shoulder instability in patients older than 40 is less common, with surgery being indicated much less compared to adolescent patients after a first-time dislocation (14% vs. 50%) (5,14). Nonetheless, up to 18% of adults over 30 years old still experience recurrent shoulder instability after primary dislocation and the decision to perform surgical stabilization versus non-surgical rehabilitation is not as clear cut as in the middle-aged population (15). There exists a dearth in the literature in evaluating the outcomes and complications after arthroscopic Bankart repair in these middle-aged patients. Henceforth, the purpose of this review is to systematically assess the indications, surgical techniques, outcomes and complications of arthroscopic Bankart repair for patients aged 30 years or older with shoulder instability. It was hypothesized that patients over 30 undergoing arthroscopic Bankart repair would achieve good post-operative outcomes (i.e., function, pain) with low complication/recurrence rates and deficits in range of motion. We present this article in accordance with the PRISMA reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-23/rc).

Methods

Study eligibility

Inclusion criteria for the current systematic review included: (I) all levels of evidence; (II) patients aged 30 years or older; (III) primary soft-tissue arthroscopic Bankart repair; and (IV) management of primary and recurrent shoulder instability. The exclusion criteria were: (I) revision procedures; (II) concomitant major shoulder procedures (e.g., glenoid reconstructions, bony procedures); (III) non-surgical management; (IV) studies without outcomes for the patient population of interest; (V) cadaver/non-human studies; and (VI) case reports.

Literature search

The online databases of PUBMED, EMBASE, and MEDLINE were searched for literature on arthroscopic Bankart repair for patients 30 years or older from database inception to February 4, 2023. The keywords used in the search strategy included “arthroscopy”, “Bankart”, “repair”, and phrases of similar nature (Table S1). The relevant keywords were inputted into Google Scholar and references of included studies were screened to ensure that articles were not missed. The research question and inclusion and exclusion criteria were established a priori.

Study selection and data abstraction

The Cochrane Handbook was used as a guideline during the preparation of this manuscript (16). A screening approach for all screening stages were designed a priori as per the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) and employed in duplicate by two independent reviewers (A.S., C.G.) (17,18). Any discrepancies at the title and abstract screening stages were resolved by automatic inclusion for thoroughness. Meanwhile, discrepancies at the full-text screening stage had input by a third reviewer (M.K.) if a consensus could not be reached by the two reviewers. Automation tools were not used in this systematic review.

A spreadsheet designed a priori in Microsoft Excel (Version 2016; Microsoft, Redmond, Washington) was used by the two reviewers (A.S., C.G.) independently to abstract the relevant data from included studies. The data collected from each article included the following categories: demographic information (e.g., author, publication year, sample size, study design, location, and patient demographics), surgical details (e.g., surgical techniques and rehabilitation protocols), post-operative outcomes (e.g., surgical and radiographic results), and complications.

Risk of bias assessment

Two tools were used to assess the methodological quality of included studies based on their study design by two independent reviewers (A.S., C.G.). Non-randomized studies (e.g., case series, cohorts, etc.) were evaluated using the Methodological Index for Non-Randomized Studies (MINORS) appraisal tool (19). The MINORS tool has a total of 12 items in which each item can have a score of either 0, 1, or 2 with a maximum score of 16 for non-comparative studies and 24 for comparative studies. Since no established guidelines existed for categorizing the quality of evidence based on the total MINORS score, the authors adopted the following criteria: scores of 0–8 (for non-comparative studies) or 0–12 (for comparative studies) were classified as poor quality; scores of 9–12 (non-comparative) or 13–18 (comparative) were considered fair quality; and scores of 13–16 (non-comparative) or 19–24 (comparative) were deemed excellent quality. Lastly, randomized controlled trials (RCTs) were evaluating using the Cochrane Risk of Bias Tool (20).

Data analysis

After consulting with a statistician, it was determined that the high statistical and methodological heterogeneity among the included studies prevented conducting a meta-analysis. Consequently, data pooling was not performed, and the findings are presented descriptively. Descriptive statistics, including counts, proportions, means, ranges, and measures of variance [e.g., standard deviation (SD), 95% confidence interval (CI)], are provided as a summary of the values reported at the final follow-up in the individual studies. Inter-reviewer agreement for assessing study quality was evaluated using the intraclass correlation coefficient (ICC), while the kappa (κ) statistic was used to assess agreement during all screening stages. Agreement levels were pre-defined as follows: ICC/κ values of 0.81–0.99 indicated almost perfect agreement, 0.61–0.80 substantial agreement, 0.41–0.60 moderate agreement, 0.21–0.40 fair agreement, and 0.20 or lower slight agreement (21). All calculations were performed using Microsoft Excel (Version 2016; Microsoft, Redmond, Washington).

Results

Study identification

The initial search identified 12,586 studies, of which 13 full-text articles met the inclusion criteria (Figure 1). These comprised nine case series, three retrospective cohort studies, and one RCT (Table 1). The detailed characteristics of all included studies are summarized in Table 1.

Figure 1 PRISMA flow diagram illustrating the systematic review process for assessing the use of arthroscopic Bankart repair in patients aged 30 years and older. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Study quality

The level of evidence amongst majority of included studies was level IV (69.2%; N=9) (Table 1). The agreement amongst the reviewers at the title/abstract and full text screening stages were κ=0.77; 95% CI: 0.73 to 0.81 and κ=0.71; 95% CI: 0.57 to 0.82, respectively, indicating substantial level of agreement. Agreement among quality assessment scores for the MINORS criteria was high (ICC =0.87; 95% CI: 0.65 to 0.95). The quality of evidence of non-randomized studies was fair, as evidenced by the mean MINORS score for non-comparative and comparative studies was 10.5±1.9 and 14.8±0.5 respectively. Overall, all non-randomized studies had prospective collection of data, and twelve studies (92.3%) had a clearly stated aim. However, only one study (7.7%) had an unbiased assessment of the endpoints. The risk of bias in the included RCT was moderate (22).

Patient characteristics

A total of 495 patients (496 shoulders; 21.4% female) with a mean age of 46.0±6.9 years were included; seven studies reported sex distribution for the population of interest (1,4,5,22,24,25,31). The mean follow-up across included studies was 57.1±48.2 months. The mean sample size per included study was 33.0±27.8 patients (range, 4–100). The mean time from initial dislocation to surgery for the population of interest was only stratified in one study (1), and was 14.1 years (range, 7.1–40 years). The mean number of dislocations prior to surgery was reported in four studies (N=85) and was 13.6±7.6 (4,5,22,24). Cause of dislocation was only reported in one study (N=38) and included daily activities (56%), traffic accidents (24%), sport activities (16%), and occupational activities (4%) (26).

Surgical indications, techniques and rehabilitation

The most common indications for isolated arthroscopic Bankart repair were history recurrent/traumatic shoulder instability (1,4,5,22-27,29), minimal glenoid bone loss (5,22,26,31), no rotator cuff tears (4,22,27,28,30), and non-engaging Hill-Sachs lesions (22,26,30). Minimal glenoid bone loss was defined as <30% (22), <20% (26), and <15% (5) across the studies that reported this as an indication for arthroscopic Bankart repair for the middle-aged patient; one study did not specify this amount of glenoid bone loss (31).

Positioning of patients intra-operatively was either lateral decubitus (46.8%; N=232), beach chair (20.4%; N=101), modified beach chair (7.5%; N=37) or not reported/unspecified (25.4%; N=126). The mean number of anchors used, reported across two studies (5,22), was 3.1±0.1 anchors; a mean was not provided, or the data was not stratified for the population of interest in the remaining studies.

Immobilization periods across studies was primarily 3 weeks (42.1%; N=209), followed by 4 weeks (29.0%; N=144), 6 weeks (15.3%; N=76) and between 4 to 8 weeks (4.8%; N=24). Time to return to sport across included studies was 6 months (38.3%; N=190), 4 months (7.1%; N=35), 8 months (4.4%; N=22), and 5 months (2.6%; N=13); this data point was not reported in four studies comprising of 236 patients (47.6%) (24,25,27,30).

Outcomes

Range of motion

Postoperative range of motion varied across included studies and included the following: external rotation with the arm at the side (range, 43°–77°), external rotation in abduction (range, 73°–84°), forward flexion/elevation (161°–174°), abduction (156.3°–169°), and internal rotation (T5–T9.2).

Carreira et al. found that patients aged 30 to 39 years had a significantly lower mean external rotation in abduction postoperatively, compared to those aged 20 to 29 years (P=0.02) (29). Delgrande et al. found that compared to the contralateral side, the shoulder undergoing Bankart repair for those aged above 30 had a significantly lower mean abduction (P=0.03), and lower external rotation both with the arm at the side (P=0.001) and with the arm abducted (P=0.002) (4).

In a case series by Ro et al. evaluating patients aged 40 years and older undergoing arthroscopic Bankart found significant postoperative deficits compared to preoperative measurements in forward flexion (P=0.04), external rotation at the side (P=0.004), internal rotation to posterior (P=0.02), cross-body abduction (P=0.01) and range of motion subscales in Rowe (P=0.009) and Constant scores (P=0.003) (1).

Ernstbrunner et al. found that compared to open Latarjet, patients aged above 40 undergoing arthroscopic Bankart repair had significantly higher active anterior elevation (P=0.01) (5).

Patient reported outcomes

Ernstbrunner et al. found that patients aged 40 and older undergoing Bankart repair had significant improvements postoperatively compared to pre-operative measures in the mean absolute Constant score (P=0.04), mean relative Constant score (P<0.001), mean pain Constant score (P<0.001) and Subjective Shoulder Value (P<0.001) (5). Another study evaluating patients aged 40 years and older undergoing arthroscopic Bankart repair found significant postoperative improvements compared to preoperative measurements in visual analogue scale during rest and motion (P<0.001), total Constant score (P<0.001) and subscales of pain (P<0.001), activities of daily living (P<0.001), and power (P<0.001), and total Rowe score (P<0.001) and subscales of stability (P<0.001), and function (P<0.001) (1). Porcellini et al. evaluating patients aged between 40 to 60 years old with isolated labral lesions undergoing arthroscopic Bankart repair found significant improvements postoperatively compared to preoperative measures in the Rowe score (P<0.001) (30).

Ernstbrunner et al. found that patients aged 40 years and older undergoing arthroscopic Bankart repair had a significantly lower final subjective shoulder value compared to patients undergoing open Latarjet at final follow-up (P=0.01) (5).

Ernstbrunner et al. evaluating arthroscopic Bankart repair in patients aged between 40 and 60 years old, with varying pathologies (i.e., isolated labrum, labrum + rotator cuff tears, labrum + superior labrum anterior posterior lesion, etc.) found that those undergoing concomitant rotator cuff repair had a significantly higher Oxford Shoulder Instability Score compared to those who did not (P=0.02) (5,25).

Return to sport rates was seldomly reported across included studies and ranged from 61–100% (5,22,31). Kraus et al. reported that patients aged 30 to 45 and 46 to 65 years of age returned to work at 2.08 months (95% CI: 1.17–3.71) and 2.95 months (95% CI: 2.17–3.92) respectively (26). There was no other reporting of mean time to return to sport or work across included studies.

Complications

The complication rate found in this systematic review was 11.3% (N=56). The most common complications included recurrent instability (i.e., frank dislocation or subluxation) (5.4%; N=27), revision surgery (4.6%, N=23), apprehension (0.8%; N=4), an intraoperative complication treated with switching to open Bankart repair (0.2%; N=1), and failure that was undefined (0.2%; N=1).

Delgrande et al. found that an ISIS score ≥3 (P=0.02), and a Hill-Sachs lesion ≥15% (P=0.001) were prognostic factors associated with failure after Bankart repair in patients aged 30 years or older (4). Ernstbrunner et al. investigating Bankart repair on patients aged 40 years and older found that advanced osteoarthritis (grade 3–4) (32,33) was significantly associated with recurrent instability (P=0.04), revision surgery (P=0.01), and longer follow-up (P=0.002) (5). This study also found that those undergoing arthroscopic Bankart repair had significantly higher recurrence rates (P=0.04) and follow-up length (P=0.001) compared to open Latarjet (5).

Discussion

The most significant finding of this systematic review was that patients over 30 years old with recurrent shoulder instability undergoing Arthroscopic Bankart repair had good to excellent post-operative patient reported outcomes with low-to-moderate complication and recurrence rates, in parallel with younger populations (3,34-39). However, patients also experienced deficits in external rotation and abduction postoperatively when comparing against younger patients, preoperative measurements, or the contralateral side. Henceforth, the a priori hypothesis has been confirmed.

Increasing age is often considered a protective factor when evaluating the risk of recurrence after Bankart repair in middle-aged patients (4,40). Delgrande et al. found a relatively high recurrence rate of 37% and attributed this to the longer follow-up (i.e., 12 years, range 10–15 years) of patients (4). Furthermore, patients in this study were selected for prior to the introduction of the instability severity index score (ISIS), in which a score of ≥3 is often viewed as a contraindication for arthroscopic Bankart repair (4,41). It is now recommended to evaluate the width of the Hill-Sachs lesion, the location of its medial margin (i.e., whether lesions are on track or off track) and the presence of a glenoid lesion on plain radiographs, in addition to the ISIS criteria, to reduce long-term recurrence rates (4,42). Moving on, Ernstbrunner et al. found that patients over 40 undergoing arthroscopic Bankart repair did not have significantly lower progression of osteoarthritis seen on radiographs compared to those undergoing the Latarjet procedure (5). This can be attributed to the microinstability of the glenohumeral joint leading to persistent cartilage damage over time despite a capsulolabral repair (5,43). However, those with recurrent instability requiring revision surgery are found to have increased disease progression of osteoarthritis (5). Hence, it is crucial to consider the clinical history and patient’s willingness to undergo such procedures despite a lack of improvement in disease progression during patient selection. In the current systematic review, the mean age was 46.0±6.9 years with a recurrence rate of 5.4%, which is slightly lower than expected. With the long-term follow-up of 57.1±48.2 months and the fact that most included studies comprised of patients with a history of recurrent dislocations prior to surgery, it would have been expected to find a higher recurrence rate postoperatively. However, this relatively low recurrence rate supports that arthroscopic Bankart repair can be successful even in middle-aged patients. Future studies should identify the utility of shoulder stabilization for middle-aged patients after a first-time dislocation.

Postoperative stiffness is a concern for middle-aged patients undergoing arthroscopic Bankart repair (44). Biomechanically, loss of external rotation has been proposed to be a result of a tight anteroinferior capsule from plication interrupting transverse movement of the subscapularis tendon during arm motion (45,46). Meanwhile, excessive immobilization after surgery can also contribute to postoperative stiffness (47). In the current review, immobilization periods varied across included studies and ranged from four to six weeks, with majority of patients being immobilized for three weeks. Thus, future studies are required to standardize rehabilitation protocols and assess immobilization periods which effectively balance between allowing proper healing while avoiding postoperative stiffness. Furthermore, with the possibility of having concomitant intra-articular disorders because of increased age, such as rotator cuff disease and chondral lesions, patients should be selected for appropriately to avoid postoperative stiffness and failure (44). In the studies included in the current systematic review, there was inadequate documentation of data to assess the impact of intra-articular glenohumeral pathology on postoperative stiffness and failure. It is unclear whether these deficits contributed to the quality of life of patients and ability to fulfill their activities of daily living. Future studies evaluating the treatment of intra-articular glenohumeral injuries in the context of instability for the middle-aged patient are required. These studies should also assess the degree of range of motion deficit that can lead to functional impairments postoperatively.

In the current review, it was found that middle-aged patients undergoing arthroscopic Bankart repair experienced good to excellent patient reported outcomes and return to sport rates postoperatively. However, when comparing to the contralateral side or those undergoing the Latarjet procedure, significant differences favouring these other groups were found (4,5,29). A proposed theory on the inability of arthroscopic Bankart repair to achieve outcomes comparable to that of the open Latarjet in middle-aged patients is that a purely soft tissue procedure is not quite as powerful as a bony procedure and can result in residual microinstability and shear stress on the glenohumeral joint, thus contributing to higher rates of instability and poorer outcomes postoperatively (5). It is unclear whether these differences in outcomes are due to the age-related changes in healing.

Strengths and limitations

This review employed a robust methodology at every stage of its development. A duplicate systematic screening process was utilized to minimize reviewer bias. Additionally, a comprehensive search across multiple databases ensured the inclusion of all relevant articles. The two reviewers demonstrated excellent agreement throughout all screening phases and during the quality assessment. Moreover, the included studies featured long-term follow-up data.

This review has limitations, primarily stemming from the quality of the available evidence. The methodological variability among the included studies (e.g., differences in patient populations, surgical techniques, and study designs) and the absence of prospective or randomized studies with long-term follow-up weaken the strength of the evidence presented in this systematic review and prevented the performance of a meta-analysis. Notably, the inclusion criterion of a minimum age of 30 years introduces heterogeneity within the patient population in this systematic review, potentially contributing to bias. Furthermore, poor documentation of data for surgical techniques (e.g., anchor placement, adjunct procedures, etc.) and outcomes (e.g., range of motion, patient-reported outcomes, return to sport, and complications) prevented our ability to ascertain the utility of arthroscopic Bankart repair in middle-aged patients with confidence. Studies also did not document humeral sided or bipolar bone loss or number of dislocations prior to surgery, thus preventing any conclusions being made on the impact of bony morphology and dislocation history on failure rates for Bankart repair in middle-aged patients. However, majority of studies utilized minimal bone loss as a major criterion to proceed with arthroscopic Bankart repair. Lastly, conclusions on optimal timing of surgery after initial dislocation could not be made as it was seldom reported.

To overcome these limitations, future research should focus on utilizing large prospective cohorts with extended follow-up periods to provide more precise estimates of failure and complication rates associated with arthroscopic Bankart repair in middle-aged adults. These studies should also improve the documentation of all data (e.g., surgical techniques, outcomes, complications) and seek to standardize arthroscopic Bankart repair in middle-aged patients based on patient factors (e.g., instability type, prior surgeries, etc.) and clinical history to better guide surgeons. Furthermore, considering that clinical history, patient goals, and postoperative success may differ among middle-aged populations, future studies should stratify all data by categorical manner (i.e., ages 30 to 40, 40 to 50 years old, etc.). Lastly, future studies should better assess the ability of middle-aged patients to return to their activities of daily living and to recreational activity.

Conclusions

Overall, there appears to be value in treating middle-aged patients experiencing anterior shoulder instability with arthroscopic Bankart repair given the moderate complication (5.4%) and revision rates (4.6%) at short-term follow-up. Postoperatively, patients experienced significant improvements in pain, function, and activities of daily living. However, this was at the expense of stiffness as there were deficits in external rotation and forward flexion. This study was primarily limited by the quality of evidence and heterogeneity. Future studies with long-term follow-up are required to identify optimal surgical management and rehabilitation protocols for this patient population based on history and clinical factors.

Acknowledgments

Parts of this systematic review were presented at the 2024 COA Annual Meeting, Halifax, ON, June 12, 2024.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-23/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-23/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-23/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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