In the Latarjet group, all 3 recorded recurrences had occurred 2 years postoperatively. One operative revision for recurrent instability as well as 4 additional revisions for other reasons than recurrent instability were necessary in the Latarjet group. One patient had a postoperative hematoma that required evacuation, 1 patient desired hardware removal, and 1 patient had the screws replaced because they were too long and irritated the infraspinatus. Finally, 1 patient required secondary shoulder arthroscopy with repair of a SLAP (superior labral anterior-posterior) tear within the observation period. Thereafter, all but 1 of these patients had an uneventful postoperative course.
In the arthroscopic Bankart group, revision surgery because of recurrent instability became necessary up to >15 years postoperatively. Of these revisions, one-third had not been performed at the time of the 5-year follow-up (Fig. 2). Two patients in the Bankart group underwent revision surgery for reasons other than recurrent instability. One patient reported shoulder pain following a sports accident 6 months after the initial surgery. Radiographic workup revealed a displaced anchor, which was removed. In another patient, a diagnostic shoulder arthroscopy and an acromioplasty were performed because of persistent pain 2 years after surgery.
In accordance with redislocation and revision rates, a similar pattern with decreasing effectiveness of the Bankart repair over time was also documented for apprehension or overt instability (Fig. 3).
The relationship between sex and recurrence rates could not be analyzed in the Latarjet group because of the small number of recurrences. In the Bankart group, redislocation occurred approximately twice as frequently in men as in women (p = 0.013) (Table III). There was, however, no significant difference between the rate of operative revisions or overall recurrence of instability between men and women.
The majority of all patients reported at least a fair postoperative result. However, there was a significantly higher percentage of dissatisfied patients in the Bankart group (13.2% versus 3.2%; p = 0.007). Furthermore, a higher percentage of highly satisfied patients was found in the Latarjet group (77.4% versus 47.5%; p < 0.0001) (Fig. 4).
Most patients were able to return to their previous sports activity, but the percentage of patients returning to their original sport was higher in the Latarjet group (p = 0.045) (Fig. 5).
While the mean SSV improved significantly in both groups (p < 0.001), the mean postoperative SSV was slightly higher in the Latarjet group (89% versus 82%; p < 0.0009). As the mean preoperative SSV in the Latarjet group was significantly lower (p < 0.0001), the overall SSV improvement was significantly larger in the Latarjet group (p < 0.001) (Figs. 6, 7, and 8). Additionally, the patients in the Latarjet group who did not report instability also had a significantly higher mean SSV (91%) compared with the Bankart patients who were free of residual instability (87%) (p = 0.002).
The number of patients with a permanent incapacity for work or who were receiving workers’ compensation payments was negligible in both groups.
In this retrospective study, the outcome of the open Latarjet procedure was substantially superior to that of the arthroscopic Bankart procedure in essentially all parameters studied. It restored stability, patient satisfaction, and SSV significantly better than the arthroscopic Bankart procedure. There were few early and almost no late failures after the open Latarjet procedure, in contrast to the arthroscopic Bankart repair, which was associated with an increasing and substantial failure rate over time.
Previous studies have documented lower rates of recurrent instability following open Latarjet procedures than after open18,22 and arthroscopic Bankart (soft-tissue) repairs12,23. To our knowledge, this study represents the largest comparative analysis of patient perception of the 2 most common procedures currently used for anterior shoulder instability with a minimum follow-up period of 6 years. We found a subjectively and/or objectively imperfect restoration of stability after 41.7% (113) of the 271 arthroscopic Bankart repairs and after 11% (10) of the 93 open Latarjet procedures, which is higher than in the existing literature12,22,23. This may be the result of longer follow-up, as many other studies likely underestimate recurrent instability because of the standard minimum follow-up of 2 years, which seems inadequate for this pathology. At the 2-year follow-up in our study, the redislocation rates were 5.1% for the Bankart group and 0% for the Latarjet group. The revision rate at the 2-year follow-up was 9.6% for the Bankart and 1% for the Latarjet repairs. In agreement with the findings of Bessière et al.23, more than half of the recurrent instabilities (61%) in our study occurred later than 2 years postoperatively and continued to occur progressively at lower rates thereafter. The contention that arthroscopic Bankart reconstructions fail progressively5,12,24 is therefore confirmed by our study, and the observation that restoration of stability with the Latarjet procedure is stable over time is supported6,8,22.
The higher rate of recurrent instability in our study might also be the result of the definition of recurrent instability. Previous studies often defined recurrent instability as redislocation alone or as redislocation and subluxation. When considering only redislocation and subluxation, we found an overall recurrence rate of 3% for the Latarjet group and 28.4% for the Bankart group. For redislocation alone, the recurrence rates were 1% and 13%, respectively, which are largely comparable with other studies in the literature.
For detailed interpretation of the restored stability, apprehension was assessed as precisely as possible. Apprehension alone may lead to substantial restriction of everyday life as well as negatively affect overall outcome and specifically sports performance. This was confirmed as 7 (1 in the Latarjet group and 6 in the Bankart group) of the 58 surgical revisions were performed for persistent apprehension without recurrent subluxation or redislocation. The transition from apprehension to subluxation may not always be perfectly clear. With the definitions outlined in the Materials and Methods section, patients appeared to be able to determine to which group they belonged or to determine that one form of instability had developed after the other.
The preoperative SSV was lower for the Latarjet patients, suggesting that the preoperative disability was greater in the Latarjet group than in the Bankart group. At the time of final follow-up, however, the mean SSV was significantly higher in the Latarjet group (89% versus 82%; p < 0.0009). Therefore, the subjective benefit of shoulder stabilization was significantly greater for the patients in the Latarjet group. We had expected that the more anatomical Bankart procedure would lead to higher subjective satisfaction in the subgroup of patients who did not have recurrent instability. Instead, we found that the Latarjet subgroup with no such instability symptoms fared significantly better (p = 0.002).
There are limitations to this study. First and foremost, this investigation was neither a randomized trial nor a controlled cohort study and therefore has an acknowledged selection bias. Shoulders with relevant glenoid rim lesions, involving >10% of the glenoid surface, are at high risk for recurrence after an arthroscopic Bankart repair18,19. Those shoulders, therefore, were not considered for arthroscopic Bankart repair. This led to a proportionally smaller group of patients without rim lesions in the Latarjet group. There is no suggestion in the literature that patients who have recurrent dislocation with an intact anterior glenoid rim are poor candidates for the Latarjet procedure. The possibility that the absence of glenoid rim lesions deselects less well-suited patients with recurrent dislocation for a Latarjet operation cannot be excluded; however, neither the results seen in our patients nor those in the literature support this hypothesis. Therefore, we assume that the patients in the Latarjet group were at greater risk for recurrence19,25-27. For clinical practice, we believed that it would be unethical to subject the patients with anterior glenoid rim lesions, who are known to have a high risk of recurrence after an arthroscopic Bankart repair and a better prognosis with a Latarjet procedure19, to a randomized trial. It appeared justified, however, to compare patients who were considered to be good candidates for an arthroscopic Bankart with patients treated with a Latarjet procedure. The results of this study, however, document a clear superiority of the Latarjet procedure, even when excluding the majority of the poor-risk patients from the Bankart group.
Furthermore, the study may be criticized because it was based on patient-reported outcome only. Although additional physical examination might have been interesting, the results of the interviews and questionnaires were found to be appropriate for answering the study questions. Because of the lack of consistent radiographic follow-up, we were not able to evaluate the development or progression of osteoarthritis. Other long-term studies, however, have not shown an increased rate of arthritic changes following Latarjet procedures compared with soft-tissue reconstructions22,24,28. The SSV, which is known to be influenced by pain, was higher in the Latarjet group than in the Bankart group at the time of final follow-up. Thus, although a difference in the development of asymptomatic osteoarthritis was not formally excluded, we think that it is an unlikely element to influence the interpretation of our data.
Last, the follow-up rate of 90% is possibly less than desired, but is satisfactory with a minimum follow-up of 6 years and a maximum follow-up of 16 years. This follow-up rate compares favorably with studies involving young, mobile patients with similar follow-up periods23.
In conclusion, the arthroscopic Bankart repair for the treatment of recurrent anterior glenohumeral joint instability is inferior to an open Latarjet procedure in our hands. It does not restore stability, patient satisfaction, or the SSV to the same level as that after an open Latarjet procedure. Failures following the osseous reconstruction procedure are rare and typically occur early in the postoperative course. The effectiveness of an arthroscopic Bankart repair decreases over the postoperative course and leads to a substantial number of late failures, with approximately 1 out of 5 first-time recurrences of instability occurring no earlier than 5 years postoperatively. Therefore, we do not recommend an arthroscopic Bankart procedure to our patients who have recurrent anterior dislocation.
Investigation performed at the Balgrist University Hospital, Zürich, Switzerland
Disclosure: The authors report no external funding source for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of this article.
1. Cole BJ, Romeo AA. Arthroscopic shoulder stabilization with suture anchors: technique, technology, and pitfalls. Clin Orthop Relat Res. 2001 ;390:17–30.
2. Wolf EM. Arthroscopic capsulolabral repair using suture anchors. Orthop Clin North Am. 1993 ;24(1):59–69.
3. Latarjet M. [Treatment of recurrent dislocation of the shoulder]. Lyon Chir. 1954 ;49(8):994–7. French.
4. Hobby J, Griffin D, Dunbar M, Boileau P. Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations. J Bone Joint Surg Br. 2007 ;89(9):1188–96.
5. Owens BD, DeBerardino TM, Nelson BJ, Thurman J, Cameron KL, Taylor DC, Uhorchak JM, Arciero RA. Long-term follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocations in young athletes. Am J Sports Med. 2009 ;37(4):669–73. Epub 2009 Feb 13.
6. Allain J, Goutallier D, Glorion C. Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder. J Bone Joint Surg Am. 1998 ;80(6):841–52.
7. Burkhart SS, De Beer JF, Barth JR, Cresswell T, Roberts C, Richards DP. Results of modified Latarjet reconstruction in patients with anteroinferior instability and significant bone loss. Arthroscopy. 2007 ;23(10):1033–41.
8. Cassagnaud X, Maynou C, Mestdagh H. [Clinical and computed tomography results of 106 Latarjet-Patte procedures at mean 7.5 year follow-up]. Rev Chir Orthop Reparatrice Appar Mot. 2003;89(8):683–92. French.
9. Collin P, Rochcongar P, Thomazeau H. [Treatment of chronic anterior shoulder instability using a coracoid bone block (Latarjet procedure): 74 cases]. Rev Chir Orthop Reparatrice Appar Mot. 2007 ;93(2):126–32. French.
10. Gazielly D. [Results of anterior coracoid abutments performed in 1995: apropos of 89 cases]. Rev Chir Orthop Reparatrice Appar Mot. 2000 ;86(Suppl 1):103–6. French.
11. Levigne C. [Long-term results of anterior coracoid abutments: apropos of 52 cases with homogenous 12-year follow-up]. Rev Chir Orthop Reparatrice Appar Mot. 2000 ;86(Suppl 1):114–21. French.
12. Bessiere C, Trojani C, Pélégri C, Carles M, Boileau P. Coracoid bone block versus arthroscopic Bankart repair: a comparative paired study with 5-year follow-up. Orthop Traumatol Surg Res. 2013 ;99(2):123–30. Epub 2013 Mar 6.
13. Schmid SL, Farshad M, Catanzaro S, Gerber C. The Latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair: a retrospective case series of forty-nine consecutive patients. J Bone Joint Surg Am. 2012 ;94(11):e75.
14. Edwards TB, Walch G. The Latarjet procedure for recurrent anterior shoulder instability: rationale and technique. Oper Tech Sports Med. 2012;20(1):57–64.
15. Nyffeler RW. Personal communication; 2016.
16. Gerber C, Nyffeler RW. Classification of glenohumeral joint instability. Clin Orthop Relat Res. 2002 ;400:65–76.
17. Walch G. Latarjet-Bristow procedure for recurrent anterior instability. Tech Shoulder Elbow Surg. 2000;1(4):256–61.
18. Bigliani LU, Newton PM, Steinmann SP, Connor PM, Mcllveen SJ. Glenoid rim lesions associated with recurrent anterior dislocation of the shoulder. Am J Sports Med. 1998 ;26(1):41–5.
19. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000 ;16(7):677–94.
20. Blazina ME, Satzman JS. Recurrent anterior subluxation of the shoulder in athletes—a distinct entity. In Proceedings of The American Academy of Orthopaedic Surgeons. J Bone Joint Surg Am. 1969 ;51(5):1037–8.
21. Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg. 2007 ;16(6):717–21.
22. Hovelius LK, Sandström BC, Rösmark DL, Saebö M, Sundgren KH, Malmqvist BG. Long-term results with the Bankart and Bristow-Latarjet procedures: recurrent shoulder instability and arthropathy. J Shoulder Elbow Surg. 2001 ;10(5):445–52.
23. Bessière C, Trojani C, Carles M, Mehta SS, Boileau P. The open Latarjet procedure is more reliable in terms of shoulder stability than arthroscopic Bankart repair. Clin Orthop Relat Res. 2014 ;472(8):2345–51.
24. Castagna A, Markopoulos N, Conti M, Delle Rose G, Papadakou E, Garofalo R. Arthroscopic Bankart suture-anchor repair: radiological and clinical outcome at minimum 10 years of follow-up. Am J Sports Med. 2010 ;38(10):2012–6. Epub 2010 Jul 1.
25. Lafosse L, Boileau P. Evaluation arthroscopique et prospective des lésions d’instabilité antérieure chronique de l’épaule. In: Christel P, Landreau P, editors. Perspectives en arthroscopie. Paris: Springer; 2002. p 193.
26. Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S. Arthroscopic stabilization for recurrent anterior shoulder dislocation: results of 59 cases. Arthroscopy. 1995 ;11(2):173–9.
27. Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am. 1984 ;66(2):159–68.
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28. Franceschi F, Papalia R, Del Buono A, Vasta S, Maffulli N, Denaro V. Glenohumeral osteoarthritis after arthroscopic Bankart repair for anterior instability. Am J Sports Med. 2011 ;39(8):1653–9. Epub 2011 May 4.