Borderline Glenoid Bone Defect in Anterior Shoulder Instability Latarjet Procedure Versus Bankart Repair Yoon Sang Jeon,* MD, Ho Yeon Jeong,y MD, Dong Ki Lee,y MD, and Yong Girl Rhee,yz MD Investigation performed at the Shoulder & Elbow Clinic, Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea Background: The optimal procedure for anterior shoulder instability with a borderline (15%-20%) bone defect on the anterior rim of the glenoid is still controversial. Purpose: To compare the clinical outcome and recurrence rate between the arthroscopic Bankart repair and Latarjet procedure among patients with recurrent anterior shoulder instability and a borderline glenoid bone defect. Study Design: Cohort study; Level of evidence, 3. Methods: The authors retrospectively reviewed cases of arthroscopic Bankart repair and the Latarjet procedure for recurrent anterior shoulder instability with a borderline (15%-20%) glenoid bone defect. Enrollment comprised 149 patients (Bankart group, n = 118; Latarjet group, n = 31). The mean follow-up and age at operation were 28.9 6 7.3 months (range, 24-73 months) and 26 6 5 years (range, 16-46 years), respectively. Results: Rowe and UCLA (University of California, Los Angeles) shoulder scores significantly improved from 42.0 6 14.3 and 22.9 6 3.2 preoperatively to 90.9 6 15.4 and 32.5 6 3.3 postoperatively in the Bankart group (P \ .001) and from 41.0 6 17.9 and 22.3 6 3.4 to 91.1 6 16.1 and 32.3 6 3.4 in the Latarjet group (P \ .001), respectively. There were no significant between-group differ- ences in Rowe (P = .920) or UCLA (P = .715) scores at the final follow-up. Mean postoperative loss of motion during forward flex- ion, external rotation in abduction, and internal rotation to the posterior was 3.0° 6 6.2°, 11.6° 6 10.2°, and 0.6 spinal segment in the Bankart group and 3.7° 6 9.8°, 10.3° 6 12.8°, and 0.9 spinal segment in the Latarjet group, respectively. These differences were not significant. However, the loss of external rotation at the side was significantly greater in the Bankart group (13.3° 6 12.9°) than in the Latarjet group (7.3° 6 18.1°, P = .034). The overall recurrence rate was significantly higher in the Bankart group (22.9%) than in the Latarjet group (6.5%), (P = .040). Conclusion: The Latarjet procedure and arthroscopic Bankart repair both provided satisfactory clinical outcome scores and pain relief for anterior shoulder instability with a borderline glenoid bone defect. However, the Latarjet procedure resulted in signifi- cantly lower recurrences and less external rotation limitation than the arthroscopic Bankart repair. Therefore, the Latarjet proce- dure could be a more reliable surgical option in anterior recurrent instability with a borderline glenoid bone defect. Keywords: shoulder; instability; anterior; glenoid defect; borderline; arthroscopic; Latarjet Patients with recurrent anterior shoulder dislocation com- accompanied by glenoid labrum detachment,5,16 and these monly have a defect in the anterior rim of the glenoid bone bony lesions are reportedly a risk factor for arthroscopic Bankart repair failure.5,7,8,31 Pagnani25 reported that patients with a large bony defect of the glenoid could z Address correspondence to Yong Girl Rhee, MD, Department of regain sufficient stability with open capsular repair and Orthopaedic Surgery, College of Medicine, Kyung Hee University, 1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Republic of Korea (email: that bone block procedures did not appear to be necessary [email protected]). for these patients. However, most studies have emphasized *Department of Orthopedic Surgery, College of Medicine, Inha Uni- the necessity of bony procedures for patients with a large versity Hospital, Incheon, Republic of Korea. 9 y defect of the glenoid. Burkhart and De Beer reported Shoulder and Elbow Clinic, Department of Orthopaedic Surgery, that for patients with anterior-inferior shoulder instability College of Medicine, Kyung Hee University, Seoul, Republic of Korea. The authors declared that they have no conflicts of interest in the attributed to trauma, those with a large bony defect had authorship and publication of this contribution. a significantly higher recurrence rate after an arthroscopic Bankart repair than those without such a lesion. The The American Journal of Sports Medicine authors indicated that in these cases, the Latarjet proce- 1–7 dure should be considered for shoulder reconstruction. Pro- DOI: 10.1177/0363546518776978 26 Ó 2018 The Author(s) vencher et al stated that for patients with recurrent 1 2 Jeon et al The American Journal of Sports Medicine shoulder instability associated with glenoid bone loss dimensional computed tomography and at least 2 years 20% to 25%, an open bone augmentation procedure is of follow-up data. The glenoid bone defect was measured required to reconstitute the glenoid osseous arc. Similarly, with the anteroposterior distance from the bare area in Boileau et al7 reported that bone loss involving 25% of the 3-dimensional computed tomography en face view.13 the glenoid surface might lead to a recurrence rate of 75%. We excluded patients with a bony Bankart lesion or engag- Accordingly, a defect involving 20% to 25% of the glenoid ing Hill-Sachs lesion and those who had undergone revi- bone has historically been considered critical bone loss that sion surgery or other concomitant procedures. The can cause recurrence; the consensus has been that arthro- concept of glenoid track described by Di Giacomo et al14 scopic soft tissue repair alone cannot sufficiently restore gle- was used to assess the engaging Hill-Sachs lesion. It was nohumeral joint stability and that an additional bony classified as an engaging Hill-Sachs lesion if the width of augmentation procedure is required in these cases.1,20,22,24,26 the humeral head defect was greater than the glenoid However, the optimal surgical treatment of anterior track.14,34 The engaging Hill-Sachs lesion was also con- shoulder instability associated with loss of 15% to 20% of firmed via arthroscopy with the arm in abduction–external the glenoid bone (ie, a borderline defect) remains controver- rotation for patients who underwent arthroscopic surgery. sial. Various reports indicate that arthroscopic soft tissue During the study period, 735 patients underwent sur- repair alone can restore stability for patients with recurrent gery for recurrent anterior shoulder instability. A total of anterior shoulder instability accompanied by a defect 28 patients with a borderline glenoid bone defect were involving 20% of the glenoid bone.11,23 However, Shaha lost to follow-up before 2 years (n = 23, arthroscopic Bank- et al28 recently reported that glenoid bone loss 13.5% art repair; n = 5, Latarjet procedure). After application of may lead to an unacceptable outcome after arthroscopic our inclusion and exclusion criteria, 149 patients were Bankart stabilization and suggested that the threshold for enrolled for analysis. The arthroscopic Bankart repair critical bone loss should be lower than the widely accepted and Latarjet operation were performed for 118 and 31 20% to 25%. In a biomechanical cadaveric study by Yama- patients, respectively. The procedure was chosen by an moto et al,35 anterior glenoid defects 19% of the glenoid operator per the clinical situation without any restriction. length caused persistent instability after Bankart lesion However, the Latarjet procedure was preferred for patients repair, and the authors suggested that the deficient glenoid with more frequent episodes of dislocation. In the Bankart cavity should be reconstructed to provide sufficient stability. group, the mean age at the time of operation was 25.6 A similar biomechanical study reported that a glenoid defect years (range, 16-42 years), and the mean follow-up period 15% of the largest anteroposterior glenoid width should be was 28.2 months (range, 24-65 months). In the Latarjet considered the critical amount of bone loss at which gleno- group, the mean age at the time of operation was 27.4 humeral translation could not be restored with isolated years (range, 21-46 years), and the mean follow-up period soft tissue repair alone and that bony restoration proce- was 30.9 months (range, 24-73 months). There were 104 dures would be required in such cases.30 However, there (88.1%) men and 14 (11.9%) women in the Bankart group has been no study comparing the clinical outcomes after and 26 (83.9%) men and 5 (16.1%) women in the Latarjet arthroscopic soft tissue repair and bony augmentation pro- group. Table 1 summarizes the characteristics of the 2 cedures for patients with recurrent anterior shoulder insta- groups. bility and a borderline glenoid bone defect. The purpose of this study was to compare the clinical Surgical Techniques outcomes and recurrence rates of the arthroscopic Bankart repair and Latarjet procedure for patients with recurrent Arthroscopic Bankart Repair. All operations were per- anterior shoulder instability and a borderline glenoid formed by a senior orthopaedic surgeon with the patient bone defect. We hypothesized that the Latarjet procedure in a 70° beach-chair position. We developed a standard pos- would provide satisfactory clinical outcomes and a lower terior viewing portal and anteroinferior and anterosupe- recurrence rate than the arthroscopic Bankart repair for rior working portals. The detached labral margin of the patients with a borderline bone defect. Bankart lesion and the glenoid rim were debrided with a motorized shaver. The glenoid rim was decorticated with a motorized bur 1 to 2 mm medially from the edge METHODS of the articular cartilage to stimulate postoperative heal- ing. A suture anchor was inserted at the 5:30- to 6-o’clock This study was approved by our institutional review board positions through the anteroinferior portal, 1 to 2 mm (Kyung Hee University Hospital, KHUH 2017-10-033-0), from the articular cartilage of the glenoid rim.