It has been estimated that 13% to 16% of patients who undergo arthroscopic stabilization procedures for recurrent shoulder instability are dissatisfied with their outcome, despite a technically “successful” operation. Similarly high rates of patient dissatisfaction in the face of an objectively “well-done” surgery are pervasive in most orthopaedic subspecialties and often leave both surgeon and patient frustrated and perplexed. Prior research has suggested that patient expectations, psychological characteristics, and socioeconomic factors play a major role in these cases of patient dissatisfaction. But identifying precise patient or injury factors that can alert surgeons as to which patients may be unsatisfied after their procedure has remained elusive for many common injuries.
In the June 19, 2019 issue of The Journal, Park et al. examine the bases for patient dissatisfaction after arthroscopic Bankart repair (with or without remplissage) for recurrent shoulder instability. Not surprisingly, patient age, size of the glenoid bone defect, and the number of patient postoperative instability events correlated with an objective failure of the operation (i.e., instability requiring a repeat operation). However, the study found that the number of instability events and the preoperative width of the Hill-Sachs lesion correlated with the subjective failure of the operation (i.e., the patient was dissatisfied based on response to a single question about “overall function” 2 years after surgery). For the 14 out of 180 patients who were dissatisfied despite not experiencing a revision, intermittent pain plus psychological characteristics such as apprehension and anxiety about recurrent instability were common reasons for dissatisfaction.
It is becoming clearer with each passing year that simply correcting anatomic pathologies does not always result in happy patients. Orthopaedic surgeons need to employ patient interviewing techniques to identify issues such as anxiety, depression, pain-perception concerns, and substance abuse—all of which can negatively influence the degree of patient satisfaction with the result and are somewhat modifiable preoperatively.
Marc Swiontkowski, MD
Under one name or another, The Journal of Bone & Joint Surgery has published quality orthopaedic content spanning three centuries. In 1919, our publication was called the Journal of Orthopaedic Surgery, and the first volume of that journal was Volume 1 of what we know today as JBJS.
Thus, the 24 issues we turn out in 2018 will constitute our 100th volume. To help celebrate this milestone, throughout the year we will be spotlighting 100 of the most influential JBJS articles on OrthoBuzz, making the original content openly accessible for a limited time.
Unlike the scientific rigor of Journal content, the selection of this list was not entirely scientific. About half we picked from “JBJS Classics,” which were chosen previously by current and past JBJS Editors-in-Chief and Deputy Editors. We also selected JBJS articles that have been cited more than 1,000 times in other publications, according to Google Scholar search results. Finally, we considered “activity” on the Web of Science and The Journal’s websites.
We hope you enjoy and benefit from reading these groundbreaking articles from JBJS, as we mark our 100th volume. Here are two more:
The Bankart Procedure: A Long-Term End-Result Study
C R Rowe, D Patel, W W Southmayd: JBJS, 1978 January; 60 (1): 1
This was the first large clinical series with long follow-up to report the findings and results of the open Bankart repair. The results were almost uniformly excellent or good, and this study contributed to the demise of nonanatomic shoulder repairs.
A Self-Administered Questionnaire for the Assessment of Severity of Symptoms and Functional Status in Carpal Tunnel Syndrome
D W Levine, B P Simmons, M J Koris, L H Daltroy, G G Hohl, A H Fossel, J N Katz: JBJS, 1993 January; 75 (11): 1585
Distinguishing interventions that work from those that don’t requires rigorous outcomes research, which, in turn, relies on standardized, patient-centered measures that have proven reliability and validity. Meeting these criteria are the Symptom Severity and Functional Status Scales for carpal tunnel syndrome described in this oft-cited JBJS study from 25 years ago.
In a retrospective case-cohort analysis of 364 shoulders that had primary repair of recurrent anterior instability, Zimmermann et al. conclude in the December 7, 2016 issue of JBJS that arthroscopic Bankart repairs were inferior to the open Latarjet procedure, at a mean follow-up of 10 years.
Specific 10-year outcome comparisons included:
- Redislocations in 13% of the Bankart shoulders vs 1% of the Latarjet shoulders
- Apprehension (fear of the shoulder dislocating with the arm in abduction and external rotation) in 29% of the Bankart patients vs 9% of the Latarjet patients
- Cumulative revision rate for recurrent instability of 21% in the Bankart group vs 1% in the Latarjet group
- Not-satisfied rating from 13.2% of patients in the Bankart group vs 3.2% in the Latarjet group
Overall, there were few early and almost no late failures after the Latarjet procedure, while the arthroscopic Bankart repair was associated with an increasing failure rate over time. The authors say that this study’s longer-term analysis confirms “the contention that arthroscopic Bankart reconstructions fail progressively” and supports “the observation that restoration of stability with the Latarjet procedure is stable over time.”
Reporting in the September 2, 2015 issue of The Journal of Bone and Joint Surgery, European researchers Moroder et al. found that 7 of 45 patients (17.5%) without substantial glenoid bone loss who underwent open Bankart repairs had a recurrence of instability during an average 22 years of follow-up.
This high failure rate is in line with findings from previous studies, but the authors include data indicating that, compared to patients who did not experience recurrent instability, “the recurrence of instability did not appear to significantly affect the subjective and objective outcome scores or the degree of work and sports impairment.”
The study found an unsurprising association between higher shoulder-specific activity levels and an increased risk for recurrence of instability. In fact, three of the seven late failures occurred during a high-energy sports accident. Etiologically, the authors hypothesize that “a lifestyle with high demands on the shoulders leads to weakening of the Bankart repair over time because of repetitive stress of the anterior capsulolabral complex.”
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