Each month during the coming year, OrthoBuzz will bring you a current commentary on a “classic” article from The Journal of Bone & Joint Surgery. These articles have been selected by the Editor-in-Chief and Deputy Editors of The Journal because of their long-standing significance to the orthopaedic community and the many citations they receive in the literature. Our OrthoBuzz commentators will highlight the impact that these JBJS articles have had on the practice of orthopaedics. Please feel free to join the conversation about these classics by clicking on the “Leave a Comment” button in the box to the left.
While our current understanding of glenohumeral dislocation has its roots in antiquity, it was not until later in the twentieth century that the orthopaedic community settled on surgical repair of the capsulolabral structures as a standard treatment. Although Perthes in 1906 and Bankart in 1923 accurately and correctly identified anterior glenoid, labral, and capsular pathology as the “essential lesion” in recurrent anterior dislocations and promoted anatomic repair, other camps favored operative treatment with non-anatomic repairs including the Putti-Platt, Magnusen-Stack, and Nicola procedures. However, by the end of the twentieth century, the Bankart repair was recognized as the “gold standard.”
“The Bankart Procedure” authored by Rowe et al (J Bone Joint Surg Am 1978; 60:1–16), is a true classic paper in the orthopaedic literature. This was the first large clinical series with good follow-up to report the findings and results of the open Bankart repair. The results were almost uniformly excellent and good, with low recurrence rates, and few complications. Although the study suffers from the usual flaws of a retrospective clinical study, it set a standard and contributed to the demise of non-anatomic repairs.
More recent innovations in arthroscopy led to the development of arthroscopic Bankart labral repairs that are now the standard of care for most surgeons treating anterior glenohumeral instability. Although greater experience with arthroscopy appears to improve outcomes, failed instability repairs are not uncommon, and this has led to expanding efforts with alternative procedures such as the Latarjet coracoid transfer and remplissage. Interestingly, the contemporary focus on severe anterior glenoid bone loss and large Hill-Sachs lesions differs from the historical perspective that “The Bankart Procedure” presented in 1978. Is this the result of changes in patient pathology or expectations, or is it driven by surgeon perceptions of outcomes and the desire to innovate? I think it is a bit of both.
Among the many points that Rowe et al. make in their landmark paper is the importance of meticulous technique. Orthopaedists often gloss over such statements in the literature, but I think most would agree that anterior instability repairs, open and arthroscopic, can be technically challenging, especially for the inexperienced surgeon. Referring to the Bankart procedure, Anthony DePalma clearly stated that “the operation is difficult and should only be performed by surgeons who are familiar with the topographic anatomy” (DePalma AF. Surgery of the Shoulder. JB Lippincott Co., Philadelphia, 1950, p. 236).
Rowe et al. correctly identified the important pathologic causes of recurrent glenohumeral instability. The most recent basic and clinical research into the more complex aspects of anterior glenohumeral instability is likely to help better define the appropriate indications for alternative procedures to address these issues.
Andrew Green, MD
JBJS Deputy Editor for the Upper Extremity