Bankart Repair in Traumatic Anterior Shoulder Instability: Open Versus Arthroscopic Technique

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1 Bankart Repair in Traumatic Anterior Shoulder Instability: Open Versus Arthroscopic Technique Seung-Ho Kim, M.D., Ph.D., Kwon-Ick Ha, M.D., Ph.D., and Sang-Hyun Kim, M.D. Purpose: The purpose of this study was to compare the results of open and arthroscopic Bankart repair using suture anchors in traumatic anterior glenohumeral instability. Variables measured were recurrence rate, range of motion, and return to preinjury activity. Type of Study: Case control study. Methods: Eighty-nine shoulders in 88 patients with traumatic unilateral anterior shoulder instability were evaluated using Rowe and University of California Los Angeles scores, recurrence, return to activity, and range of motion by an independent examiner at an average of 39 months after either an arthroscopic or open Bankart repair using suture anchors. The arthroscopic technique included a minimum of 3 anchors in most patients and a routine incorporation of capsular plication and proximal shift. Of the 89 shoulders, 30 shoulders (30 patients) underwent open Bankart repair and 59 shoulders (58 patients) underwent arthroscopic Bankart repair. Results: Twenty-six shoulders (86.6%) in the open repair group showed excellent or good results, and 54 (91.5%) shoulders in the arthroscopic repair group showed excellent or good results. The arthroscopic group revealed slightly higher scores in the Rowe (P.041) and UCLA scores (P.026). Two patients (6.7%) in the open repair group and 2 (3.4%) in the arthroscopic repair group had experienced at least 1 episode of redislocation after the surgery. One patient (3.3%) in the open repair group and 4 (6.8%) in the arthroscopic repair group demonstrated mild apprehension. The overall residual instability was 10% in the open repair group and 10.2% in the arthroscopic repair group. There were no significant differences in the loss of external rotation and return to prior activity between the 2 groups (P.05). Residual instability occurred more frequently in patients with fewer anchors. Conclusions: Arthroscopic suture anchor capsulorraphy showed similar results to the open Bankart procedure. Key Words: Anterior instability Bankart repair Open Arthroscopy Result Suture anchor Shoulder. Bankart repair has been an established procedure to treat recurrent traumatic anterior instability of the shoulder. Rowe et al. 1 reported highly successful results with the Bankart procedure. In this procedure, the lateral capsular flap was repaired directly to the glenoid and the labrum was incorporated into the repair. Recent experience with arthroscopic anterior From the Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, and Sungkyunkwan University Sports Medicine Institute, Seoul, Korea. Presented at the 19th Annual Meeting of the Arthroscopy Association of North America, Miami, Florida, April 15, Address correspondence and reprint requests to Seung-Ho Kim, M.D., Ph.D., Department of Orthopaedic Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, 50 Ilwon-Dong, Kangnam-Ku, Seoul, Korea smcknot@hotmail.com 2002 by the Arthroscopy Association of North America /02/ $35.00/0 doi: /jars shoulder stabilization has been challenging the conventional open reconstruction techniques. 2-7 However, the results of arthroscopic shoulder reconstruction are still less satisfactory than open repair Nevertheless, there have been only a few articles addressing the comparative results of open and arthroscopic Bankart repairs. 13,15,16 Furthermore, no report has compared the results of the open procedure with the arthroscopic technique using suture anchors. Therefore, the goal of this study was to compare the results, including recurrence rate, range of motion, and functional level of return to preinjury activity, of open and arthroscopic Bankart repair using suture anchors for the treatment of traumatic anterior glenohumeral instability. METHODS From January 1994 to December 1996, 93 anterior shoulder stabilization procedures were performed by Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 7 (September), 2002: pp

2 756 S.-H. KIM ET AL. the same surgeon in 92 patients with traumatic recurrent anterior dislocation of the shoulder. With an average follow-up of 39 months (range, 26 to 60 months), 89 shoulders in 88 patients were available for a retrospective analysis. Patients with full-thickness rotator cuff tear, greater tuberosity fracture, capsular tear at the humeral insertion, or previous surgery of the shoulder were excluded. Of the 89 shoulders, 30 (30 patients) had undergone open Bankart repair using Mitek GII suture anchors (Mitek Surgical Products, Norwood, MA) and 59 shoulders (58 patients) had undergone arthroscopic Bankart repair using mini-revo screws (Linvatec, Largo, FL). Open Bankart repairs were performed during the initial part of the index period, and the arthroscopic procedures were performed during the latter part of the time period. Therefore, there was no preselection for the each type of surgery. The average follow-up was 49 months (range, 41 to 60) in the open repair group and 33 months (range, 26 to 42) in the arthroscopic repair group. Patient Demographics The average age of the patient was 27.6 years (range, 18 to 47) and 26.7 years (range, 16 to 51) in the open and arthroscopic groups, respectively. There were 26 men and 4 women in the open group, and 50 men and 8 women in the arthroscopic group. Fourteen patients in the open group were actively involved in sports activities (9 in overhead sports, 5 in contact sports, 6 in collegiate or professional sports, 8 in recreational level sports) and 32 patients in the arthroscopic repair group were actively involved in sports activities (21 in overhead sports, 11 in contact sports, 10 in collegiate or professional, 22 in recreational level). Six shoulders in the open group and 13 shoulders in the arthroscopic group had a grade II or greater asymptomatic sulcus sign. The biceps load test 17 was positive in 10 shoulders in the arthroscopic group; the test was not performed in the open group. Differing numbers of anchors were used: 2 anchors were used in 12 (40%) shoulders and 3 anchors in 18 (60%) shoulders of the open repair group. In the arthroscopic group, 2 screws were used in 2 shoulders (3.4%), 3 screws in 26 shoulders (44.1%), 4 screws in 22 shoulders (37.3%), and 5 screws were used in 9 shoulders (15.2%). The number of dislocations before the index surgery, the elapsed time from the first dislocation to the surgery, and patient age at the initial dislocation are summarized in Table 1. TABLE 1. Variables Arthroscopic Findings Evaluating the grade of the humeral translation under general anesthesia as suggested by Altchek et al., 18 we found grade 3 anterior translations in 22 shoulders and grade 2 in 8 shoulders of the open repair group, while the arthroscopic group showed grade 3 in 48 shoulders and grade 2 in 11 shoulders. Hill- Sachs lesions were found in all patients. The anterior labrum of the Bankart lesion was classified into 3 categories; robust, signifying discrete labral tissue with a thickness greater than half of the other part of the labrum; thinned, signifying thickness of the labral tissue less than half of the other part of the labrum; and absent, signifying no discernible labral tissue while preparing the capsular tissue in the anteroinferior aspect of the glenoid. Fifteen shoulders in the open group and 38 in the arthroscopic group had a robust anterior labrum (Table 2). Bony Bankart lesions were found in 4 patients (13.3%) in the open repair group and 9 patients (15.3%) in the arthroscopic repair group. Three of 13 patients with bony Bankart lesions revealed a large defect (greater than 30% of the glenoid circumference) in the anterior glenoid margin. However, the bony Bankart fragment was not severe enough to necessitate fixation to the glenoid. Operative Technique Patient Demographics Open Repair Group Arthroscopic Repair No. of patients (59 shoulders) Average age at initial dislocation (yr) 20.3 (16-41) 19.5 (14-32) Median no. of dislocations 12 (3-100) 10 (2-100) Average time from injury to surgery (yr) 4.9 (0.6-16) 5.8 (0.3-19) The open Bankart repair was carried out with the patient in the beach-chair position. In all patients, examination under general anesthesia and diagnostic arthroscopic examination were performed initially. Through the modified anterior deltopectoral approach, beginning the skin incision at the axillary crease, the deltopectoral groove was opened and the cephalic vein was retracted laterally with the deltoid muscle. With the arm in the external rotation position, the superior two thirds of the subscapularis was incised vertically at 1 cm medial from its insertion to the lesser tuber-

3 BANKART REPAIR IN TRAUMATIC ANTERIOR SHOULDER 757 Variables TABLE 2. Arthroscopic Findings Open Repair Group Arthroscopic Repair Anterior labrum Robust Thinned Absent 5 7 Hill-Sachs lesion Large defect Superficial bony lesion Cartilage scuffing 4 8 Superior labral lesion Type II 4 11 Type III 2 4 ASPTRCT 3 (Ellman grade I) 7 (5, grade I; 2, grade II) Abbreviation: ASPTRCT, articular surface partial-thickness rotator cuff tear. osity. The capsule was gently separated from the subscapularis tendon medially to the glenoid and inferiorly to the 6 o clock position. A curved incision was made a few millimeters lateral to the margin of the anterior glenoid. Two or 3 traction sutures were placed on the lateral lip of the anterior capsule. A sharp periosteal elevator was used to peel off the anterior labrum (Bankart lesion) from the glenoid wall, and a light decortication was performed on the glenoid margin and the medial wall. Two or 3 drill holes were created on the margin of glenoid. Mitek anchors with No. 2 nonabsorbable sutures (Ethibond; Ethicon, Somerville, NJ) were inserted. The anterior labrum with the medial lip of the anterior capsule was sutured with inside-to-out direction and tied over the anterior capsule. While the traction sutures in the lateral lip of anterior capsule were pulled proximally and medially to adjust the tension of the anterior capsule, the lateral lip was sutured over the medial capsule with the same suture in the suture anchor, resulting in plication and the proximal shift of the anterior capsule. During the capsular repair, the shoulder was maintained at 30 external rotation position. The edge of the lateral lip was augmented on the medial lip using the traction sutures. A routine repair of the subscapularis and skin were made. Pendulum exercise was started after sling immobilization for 2 weeks. After 3 weeks, progressive active and assisted forward elevation exercise was initiated using a rope and pulley. External rotation was permitted up to the neutral position. After 4 weeks, internal and external rotation strengthening exercises were initiated using a rubber band. After 6 weeks, external rotation beyond neutral, with the arm either in the dependent position or in elevation, was started. For the arthroscopic Bankart repair, patients were positioned in the lateral decubitus position, while the standard posterior, anterosuperior, and anteroinferior portals were created. Working from the anterosuperior portal, the capsulolabral tissue was mobilized from the anterior glenoid surface (Fig 1) and light decortication using a bone rasp or 4.5 mm burr was performed (Fig 2). With a 2-mm pituitary forceps, small pilot markings on the margin of the anterior glenoid rim were created. The first anchor site was at the 5:30 position for the right shoulder and the 6:30 position for the left shoulder (Fig 3). With a special bone punch (Linvatec), a hole for the screw was created as vertical to the glenoid margin as possible. This procedure was performed by keeping the tip of the bone punch in the pilot marking and pivoting the shaft of the bone punch inferiorly and laterally (Fig 4). A mini-revo screw with a No. 2 Ethibond suture was inserted into the hole. Using the suture hook loaded with the Shuttle- Relay (Linvatec), a capsular suture was created at about 1 cm inferior to the anchor and at the same level as the glenoid surface (Fig 5). The amount of capsular shift depended on redundancy of the capsule. We regarded the capsule as redundant if one of the following signs was identified: FIGURE 1. Arthroscopic view showing mobilization of the Bankart lesion (right shoulder viewed from the anterosuperior portal). Arrow indicates liberator knife (A, humeral head; B, glenoid; C, anterior labrum).

4 758 S.-H. KIM ET AL. FIGURE 2. Arthroscopic view showing light decortication of the anterior glenoid wall (right shoulder viewed from the anterosuperior portal). Arrow indicates the meniscal rasp (A, humeral head; B, glenoid; C, anterior labrum). FIGURE 4. Arthroscopic view showing creation of the screw hole using a bone punch (arrow). Right shoulder viewed from the anterosuperior portal (A, humeral head; B, glenoid; C, anterior labrum). thumb-to-forearm distance less than 4 cm; sulcus sign greater than 2 ; an anterior capsule that created a large inflated pouch when the joint was distended by the irrigation fluid and that was introduced onto the FIGURE 3. Arthroscopic view showing creation of the pilot marking for the most inferior screw (right shoulder viewed from the anterosuperior portal). Arrow indicates a 2-mm pituitary forceps (A, humeral head; B, glenoid). FIGURE 5. Arthroscopic view showing capsular shift and plication (right shoulder viewed from the posterior portal). The suture hook is loaded with a Shuttle-Relay and pierces the anteroinferior capsule at about 1 cm inferior to the suture anchor and at the same level as the glenoid surface. Arrow indicates the suture hook (A, humeral head; B, glenoid; C, anterior labrum).

5 BANKART REPAIR IN TRAUMATIC ANTERIOR SHOULDER 759 FIGURE 6. Arthroscopic view showing capsular shift and plication (right shoulder viewed from the posterior portal). The suture hook, with the capsular tissue, was shifted proximally to the point of the suture anchor. Arrow indicates the suture hook (A, humeral head; B, glenoid). FIGURE 7. Arthroscopic view showing capsular shift and plication (right shoulder viewed from the posterior portal). The suture hook was passed under the labrum. Arrow indicates the suture in the suture anchor (A, humeral head; B, glenoid; C, anterior labrum; arrowhead, Shuttle-Relay). glenoid surface when the irrigation fluid was deflated (deflation phenomenon). In shoulders with capsular redundancy, the capsule was shifted more than 1 cm. Otherwise, the proximal shift was within 1 cm. The suture hook, with the capsular tissue, was shifted proximally to the point of the suture anchor (Fig 6), and then the suture hook was passed under the labrum (Fig 7). One end of the suture was engaged into the eyelet of the Shuttle-Relay and then pulled back out. Finally, an arthroscopic knot was made (the SMC knot 19,20 ) (Fig 8). We used a minimum of 3 anchors for most of the patients, and as many as 6 for the anterior labral repair. An additional 1 to 3 anchors were used for the superior labral repair when indicated. Postoperatively, a sling with a pillow spacer was applied for 3 weeks and pendulum exercise was initiated 2 weeks after the operation. From 3 weeks after the operation, forward elevation and internal rotation exercises were commenced using the home therapy kit (Shoulder Therapy Kit; Breg, Vista, CA). More aggressive physical therapy was started 6 weeks after the operation. Evaluation Final evaluations, including the Rowe score 1 and University of California Los Angeles (UCLA) shoul- FIGURE 8. Arthroscopic view showing complete repair of the Bankart lesion (right shoulder viewed from the posterior portal). (A, humeral head; B, glenoid; C, repaired anterior labrum.)

6 760 S.-H. KIM ET AL. der rating scale, 21 were conducted by an independent reviewer. Successful return to previous employment or athletic activity level was subjectively evaluated by the patients using a visual analog scale. Grade 0 represented no limitation of sports activities and a complete return to the prior job (100% of preinjury level). Grade I was mild limitation in sports activities and return to prior job (more than 90% of preinjury level). Grade II signified that the patient had moderate limitation of sports activities or job even though the patient continued prior job or sports activities (more than 70% of preinjury level). Grade III represented severe limitation (less than 70% of preinjury level) or inability to return to prior sports activities or previous job. Grade 0 and I were classified as favorable results, while grade II and III were classified as unfavorable results. Statistics The Rowe and UCLA scores were compared between the two groups using the Mann-Whitney U test. Spearman s correlation coefficients were used to identify any significant relationships between the final scores and several variables. A nonparametric Kruskal-Wallis test was performed to determine differences in follow-up scores between different conditions of the anterior labrum in both groups. Also, the difference in the functional return to preinjury levels of activity between the groups was evaluated. A Chisquare test was used to evaluate the difference in the residual instability in relation to the number of anchors used in both groups and to evaluate the difference of residual instability between the open and arthroscopic group with the given number of anchors at 2 and 3. The SPSS program (SPSS, Chicago, IL) was used for all analysis, with the statistical significance level set at P.05. Overall Scores RESULTS At the follow-up, 26 patients (86.6%) had good or excellent results, 2 (6.7%) fair, and 2 (6.7%) poor in the open Bankart repair group. In the arthroscopic repair group, 54 (91.5%) had good or excellent results, 3 (5.1%) fair, and 2 (3.4%) poor. The average Rowe and UCLA scores improved significantly after the surgery in both groups (P.05) (Table 3). The arthroscopic group revealed slightly higher follow-up scores than the open group on the Rowe (P.041) and UCLA rating scales (P.026). Scores The final results were not related to variables such as sex, rotator cuff tear, number of dislocations, elapsed time from the initial dislocation, grade of translation, presence of generalized laxity, Hill-Sachs lesion, condition of the anterior labrum, level of activity, or bony Bankart lesions. However, in the arthroscopic repair group, a significant positive correlation was found between the Rowe score and the age at initial dislocation (r.807). Fifteen patients younger than 20 years of age at initial dislocation demonstrated lower scores (mean, 84.9 points; standard deviation [SD], 17.7; 95% confidence interval, 75.8 to 94.0 points) than 43 patients who were 20 years of age or older (mean, 95.7 points; SD, 6.9; P.029; 95% confidence interval, 93.6 to 97.8 points). Recurrence TABLE 3. Two patients (6.7%) in the open repair group and 2 (3.4%) patients in the arthroscopic repair group experienced at least 1 episode of redislocation after the surgery. One patient in the open repair group had a redislocation as a result of sports trauma while playing basketball, 3 years after the surgery. The other patient had a redislocation 2 years after the surgery while skiing. In the arthroscopic repair group, 1 patient sustained a forceful external rotation injury during basketball, 2 years after surgery; the other patient experienced a redislocation while attempting to perform a chin-up, 17 months after the surgery. All patients underwent reoperation with the arthroscopic suture anchor technique. All patients had Bankart lesions and the failure sites were the same as the previous lesions. The suture materials were pulled out from the anchors or from the capsulolabral tissue. No anchors were pulled out of the glenoid. Apprehension Open Repair Rowe and UCLA Scores Arthroscopic Repair Preoperative Follow-up Preoperative Follow-up Rowe 39.7 (20-50) 90.4 (30-100) 38.8 (20-50) 92.7 (40-100) UCLA 23.4 (14-28) 30.6 (20-35) 24.7 (16-28) 33.1 (18-35) One patient (3.3%) in the open repair group and 4 (6.8%) in the arthroscopic repair group demonstrated mild apprehension with the arm in the elevation and external rotation position. However, these patients did not have significant trauma after the Bankart repair.

7 BANKART REPAIR IN TRAUMATIC ANTERIOR SHOULDER 761 Overall Instability Overall residual instability including mild apprehension was observed in 10% of the open repair group and 10.2% of the arthroscopic repair group. The Chisquare test revealed significant difference in the residual instability between the groups with different numbers of screws in the arthroscopic repair group (P.001). In the open repair group, the difference was statistically insignificant, although the P value was low (P.082). Given a number of anchors of 2 or 3, there was no difference in residual instability between the open and arthroscopic groups. No significant correlation was found between residual instability and other variables. The condition of the anterior labrum revealed no significant correlation with residual instability in our study (r.136) (Table 4). Range of Motion There were no significant differences in the average loss of external rotation between the 2 groups (P.05). The average loss of external rotation at the side was 4.3 (range, 0 to 20 ; SD, 4.2 ) and 3.5 (range, 0 to 20 ; SD, 5.7 ) in the open and arthroscopic groups, respectively. In the 90 abduction position, the average loss of external rotation was 5.7 (range, 0 to 25 ; SD, 7.4 ) in the open group and 3.6 (range, 0 to 20 ; SD, 4.1 ) in the arthroscopic group. However, there was a significant difference in the proportion of patients with limitation of external rotation greater than 10 (P.027). Seven (23.3%) shoulders in the open repair group and 4 (6.8%) shoulders in the arthroscopic repair group demonstrated a limitation of TABLE 4. Patient Number of Anchors and Type of Anterior Labrum in Patients With Recurrence Age/ Gender Recurrence No. of Anchors Anterior Labrum Open repair 1 23/M Dislocation 2 Absent 2 31/M Dislocation 2 Robust 3 26/M Apprehension 2 Robust Arthroscopic repair 1 26/M Dislocation 2 Robust 2 23/M Dislocation 3 Robust 3 24/F Apprehension 2 Thinned 4 27/M Apprehension 3 Absent 5 27/M Apprehension 3 Absent 6 30/M Apprehension 3 Thinned P.082 for the number of anchors in the open group; P.000 for the number of anchors in the arthroscopic group; r.136 for the condition of the anterior labrum. TABLE 5. Loss of ERabd more than 10 of external rotation with the arm in the 90 abduction position (Table 5). Return to Activity There were no significant differences in return to activity between the open and arthroscopic group (P.256). However, the grade of activity return was different between the different level of sports activity engaged in prior to injury. Patients with a higher level of activity demand demonstrated a lower grade of return to the previous activity level (P.002). Collegiate or professional athletes rated their returns to their preinjury level of sports activity as less favorable than the group of patients without regular preinjury athletic activity (P.001). There were no significant differences in the return to activity between the different types of sports activity (P.05). Superior Labral Lesion In both groups, the superior labral lesion was unrelated to age at the initial dislocation, the number of dislocations, or the elapsed time from the initial dislocation. Also, the repair of the SLAP lesion did not alter the final Rowe or UCLA scores (P.05). Complication Loss of External Rotation With the Arm in 90 of Abduction Open Repair Group Arthroscopic Repair Abbreviation: ERabd, External rotation with the arm in 90 of abduction. Transient paresthesia of the involved upper extremity was noted in 3 patients in the arthroscopic repair group. These occurred in initial patients who had an excessive longitudinal and lateral traction. In all patients, the paresthesia was relieved without any consequence within a few weeks. We abandoned the lateral traction thereafter, and the longitudinal traction was maintained at less than 10 lb. There was no major neurovascular complication or infection in either group.

8 762 S.-H. KIM ET AL. DISCUSSION The most striking difference in our study from previous reports is the high recurrence rate in the arthroscopic reconstruction group compared with the uniform low rate of recurrence in the open Bankart repair group. 5,8,9,22-28 With the advancement of arthroscopic technique, arthroscopic Bankart procedures are performed increasingly often. Nevertheless, only a few reports on the comparative results between the open and arthroscopic Bankart repair have been published. 16,17,29 Guanche et al. 16 reported that arthroscopic shoulder stabilization generally produced poorer results than open procedures. However, the patients in that study were small, heterogeneous groups, in both the arthroscopic and open repair groups. Arthroscopic Bankart repair with the suture anchor technique is a relatively new procedure, and therefore, has not undergone long-term evaluation. In an earlier report on arthroscopic Bankart repair using Mitek G II anchors, Wolf et al. 29 showed promising results. However, Koss et al. 10 reported a 30% failure rate in 27 patients with arthroscopic Bankart repair using Mitek G II anchors. All unsuccessful results were due to recurrent dislocation or subluxation. They suggested that the number of anchors used was not related to successful results. However, information on the number of anchors used was only available for 21 of 27 patients. Furthermore, 17 of 21 patients had 1 or 2 anchors and only 4 patients had 3 or 4 anchors. In our study, patients in the arthroscopic group with fewer anchors developed a greater incidence of residual instability. In the open repair group, although the statistical analysis was insignificant, all residual instability occurred in patients with 2 anchors. Arthroscopic Bankart repair using the suture anchor technique has advantages over other arthroscopic techniques in that it uses an anterior fixation and individual suture knot on the glenoid margin. In the present study, the results of arthroscopic suture anchoring were not inferior to those of open repair. Residual instability and return to activity were similar in both groups. The follow-up shoulder scores were slightly higher in the arthroscopic group, although the differences are too minor to suggest clinical significance. We believe that the comparable results in the arthroscopic suture anchor group are attributable to a number of features in our arthroscopic procedure. Our technique used a minimum of 3 screws in 96.6% of the shoulders for repair of the anterior labrum and incorporated a proximal shift of the anterior capsule and a capsular plication as a routine procedure. The capsular suture was level with the glenoid surface, which eliminated a pouch in the anterior and inferior capsule. The rationale of this technique is based on the study by Bigliani et al. 30 of the elongation of the anterior glenohumeral ligament preceding labral failure during shoulder dislocation. Because of the routine capsular plication and proximal shift, the average loss of external rotation in the arthroscopic repair group was no better than the open repair group. However, a significant loss of external rotation was less common in the arthroscopic repair group. This implies that the arthroscopic repair group had a more uniform degree of loss of external rotation at the lower level, which was less than 10. This in turn gave the arthroscopic patient a more functional range of motion and resulted in better follow-up scores. Shoulder function after the Bankart repair is one of the important concerns. However, only a few reports include direct comparisons of functional return to preinjury sports or employment between the groups. Guanche et al. 16 reported that 33% of patients in both the arthroscopic and open repair groups showed impaired ability to throw. The patients in their study had participated in sports before injury, although none were professional or collegiate varsity athletes. In our study, subjective evaluations by patients were similar in both groups. However, return to preinjury sports activity or job tasks were the best in patients without regular sports activity and the worst in collegiate or professional athletes. Athletes in both groups stated that they still had some discomfort while performing at their maximum level of activity. The condition of the anterior capsule and labrum may affect the results of the Bankart repair. Green and Christensen 9 reported a high recurrence rate in shoulders with a poor capsulolabral condition. Many authors agreed that proper selection of patients is essential for successful capsulolabral reconstruction. 9-13,31 In contrast, we found no significant differences in recurrence rates for patients with different conditions of the labrum despite the fact that there was no screening of patients for an optimal arthroscopic repair. We believe that capsular plication and proximal shift played a role in the shoulders with a thin or no anterior labral structure as well as the number of screws used for fixation. Our current indication for arthroscopic Bankart repair is any traumatic anterior instability, except for patients with capsular tear at the humeral attachment, large glenoid rim fracture greater than 30% of the

9 BANKART REPAIR IN TRAUMATIC ANTERIOR SHOULDER 763 glenoid circumference, tuberosity avulsion fracture, or failed arthroscopic revision Bankart repair. Open Bankart repair is indicated for these patients. Although this is the first comparative study of open and arthroscopic Bankart repairs in patients with similar demographics, the research also has several weak points. The project is retrospective in nature with nonrandomly selected subjects. Also, the follow-up was 16 months longer for the open repair group, which is a major flaw, because arthroscopic repair results can deteriorate over time. 5 Despite these drawbacks, however, we can conclude that arthroscopic Bankart repair using a suture anchor technique that includes a minimum of 3 anchors and routine incorporation of capsular plication and proximal shift together yields a success rate similar to the open Bankart repair using suture anchors. These results were measured in terms of recurrence rate, Rowe and UCLA scores, and the level of return to prior activity. However, a prospective randomized study comparing both techniques is essential for further investigation. REFERENCES 1. Rowe CR, Patel D, Southmayd WW. The Bankart procedure. A long-term end-result study. J Bone Joint Surg Am 1978;60: Benedetteo KP, Glötzer W. Arthroscopic Bankart procedure by suture technique: Indications, technique and results. Arthroscopy 1992;8: Caspari RB. Arthroscopic reconstruction for anterior shoulder instability. Tech Orthop 1988;3: Morgan CD. Arthroscopic transglenoid suture repair. Oper Tech Orthop 1991;1: Organ SW, Siekanowicz AJ, Nirschl RP, Pettrone FA. Arthroscopic transglenoid suture capsulolabral repairs: Five year follow-up. Orthop Trans 1996;20: Savoie FH III, Miller DC, Field LD. Arthroscopic reconstruction of traumatic anterior instability of the shoulder: The Caspari technique. 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