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Treatment of Bankart Lesions in Traumatic Anterior Instabilityof the Shoulder: A Randomized Controlled Trial Comparing

Arthroscopy and Open Techniques

Nicola Archetti Netto, M.D., Ph.D., Marcel Jun Sugawara Tamaoki, M.D., Ph.D.,Mario Lenza, M.D., Ph.D., João Baptista Gomes dos Santos, M.D., Ph.D.,Marcelo Hide Matsumoto, M.D., Ph.D., Flavio Faloppa, M.D., Ph.D., and

João Carlos Belloti, M.D., Ph.D.

Purpose: The objective of this study was to compare the functional assessments of arthroscopy andopen repair for treating Bankart lesion in traumatic anterior shoulder instability. Methods: Fifty adultpatients, aged less than 40 years, with traumatic anterior shoulder instability and the presence of anisolated Bankart lesion confirmed by diagnostic arthroscopy were included in the study. They wererandomly assigned to receive open or arthroscopic treatment of an isolated Bankart lesion. In all casesof both groups, the lesion was repaired with metallic suture anchors. The primary outcomes includedthe Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Results: After a meanfollow-up period of 37.5 months, 42 patients were evaluated. On the DASH scale, there was astatistically significant difference favorable to the patients treated with the arthroscopic technique, butwithout clinical relevance. There was no difference in the assessments by University of California,Los Angeles and Rowe scales. There was no statistically significant difference regarding complica-tions and failures, as well as range of motion, for the 2 techniques. Conclusions: On the basis of thisstudy, the open and arthroscopic techniques were effective in the treatment of traumatic anteriorshoulder instability. The arthroscopic technique showed a lower index of functional limitation of theupper limb, as assessed by the DASH questionnaire; this, however, was not clinically relevant. Levelof Evidence: Level II, randomized controlled trial.

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The treatment of traumatic anterior shoulder insta-bility associated with Bankart lesion remains

controversial in orthopaedics. The anatomic repair ofthe capsulolabral complex of the glenoid has become thegold-standard treatment for the referred disease since the

From the Division of Hand and Upper Limb Surgery, Depart-ent of Orthopedics and Trauma, Universidade Federal de Sãoaulo–Escola Paulista de Medicina, São Paulo, Brazil.The authors report that they have no conflicts of interest in the

uthorship and publication of this article.Received May 2, 2011; accepted November 22, 2011.Address correspondence to Marcel Jun Sugawara Tamaoki,.D., Ph.D., Department for Orthopedic Surgery and Traumatol-

gy, Hospital São Paulo, Rua Borges Lagoa 786, 04038-001 Sãoaulo (SP), Brazil. E-mail: marceltamaoki@terra.com.br© 2012 by the Arthroscopy Association of North America0749-8063/11273/$36.00

doi:10.1016/j.arthro.2011.11.032

Arthroscopy: The Journal of Arthroscopic and Related

findings obtained by Bankart in 1938.1-4 In the 1980s, thereatment of Bankart lesion was the minimally inva-ive approach of arthroscopy. The main advantages ofhis method are less damage to the soft tissues, shorteruration of surgery, shorter hospital stay, and lowostoperative complication rate, and some studies re-ort lower postoperative restriction of the range ofotion.5-7 The main criticism of this method concerns

the significant recurrence rate of shoulder dislocationscompared with the open technique.8-11 Recently, aystematic review concluded that there was a lowerecurrence rate of shoulder dislocation in favor ofrthroscopic technique.12 However, there are fewomparative studies with an adequate design analysisethod to corroborate this conclusion.12 The purpose

of this prospective and randomized study was to com-

pare the outcomes of arthroscopy and open repair for

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traumatic anterior shoulder instability in a homogeneousgroup of patients, assessing postoperative function andrecurrence.

Our hypothesis was that using the arthroscopic tech-nique would result in more favorable Disabilities ofthe Arm, Shoulder and Hand (DASH) score assess-ment compared with the open technique.

METHODS

This randomized trial was conducted from Novem-ber 2003 to December 2006 (ISRCTN22171602).

Inclusion criteria for the study group were (1) adultpatients aged less than 40 years; (2) patients with morethan 1 episode of shoulder traumatic dislocation, withat least 2 anteroposterior- and lateral-view radiographsshowing anterior shoulder dislocation; (3) clinical his-tory of traumatic anterior instability of the shoulder,with positive apprehension or relocation tests, as wellas an asymptomatic contralateral shoulder; and (4)arthroscopic confirmation of Bankart lesion. The ex-clusion criteria were (1) patients with multidirectionaland/or voluntary instability; (2) patients with convul-sive disorders, collagen diseases, previous shouldersurgeries, and any other conditions that might affectthe mobility of the joint; (3) patients with bony gle-noid lesion confirmed by radiographic examination;(4) arthroscopic visualization of an “engaging Hill-Sachs lesion” and/or inverted-pear glenoid13; (5) pa-ients with SLAP lesion types II, III, and IV, accord-ng to the classification of Snyder et al.,14 and/orartial- or full-thickness rotator cuff tears, confirmedy arthroscopy; and (6) patients who refused to signhe consent form.

Sample size estimations were performed before theecruitment of the patients. The main variable usedas the DASH questionnaire.15,16 Type I error was

pre-established as 5% (95% confidence interval) andtype II error as 20% (power of 80%) with a populationstandard deviation of 18%.

To calculate our sample size, we used the followingmathematic method:

n � ��Z� ⁄ 2 � Z��2 · �2� ⁄ �2

where Z�/2 is the critical value � from the standardnormal distribution with upper tail, Z� is the criticalalue � from the standard normal distribution, � is theopulation standard deviation, and � is the differencen the DASH questionnaire, which was assumed to belinically relevant.

The values Z�/2 (type I error) and Z� (type II error)

ere obtained by standard normal distribution tables.

hus, assuming the values described in the text, weave anticipated that 25.4 participants would be re-uired in each group.After signing informed consent forms, the patientsere sequentially included and randomly allocated toof the surgical procedures, by use of a computer-

enerated randomization schedule—Research Ran-omizer computer software, developed by Geoffrey C.rbaniak and Scott Plous. After the verification of the

rthroscopic inclusion criterion, the randomization toither arthroscopic or open technique was made byndividuals not directly related to the study using aequentially numbered, opaque, sealed envelope.

All the patients underwent general anesthesia asso-iated with brachial plexus block and attended theutpatient clinic during the postoperative period. Theurgical interventions were performed by 4 surgeonsith experience in both techniques, according to the

ame pre-established protocol. At first, the patientsnderwent diagnostic arthroscopy in the beach-chairosition, and only after verification of the inclusionnd exclusion criteria were the envelopes with theescription of the randomized procedure (open orrthroscopic technique) opened.

reatment of Bankart Lesion by Open Technique

The surgical technique was the modified Bankartrocedure described by Matsen et al.17 (Fig 1). The

patients were placed in the beach-chair position, andsurgery was performed with a deltopectoral incisionwith subscapularis detachment. Repair of the Bankartlesion was performed with 4 � 13 � 2–mm threadedmetal anchors (Hexagon Brasil, Campinas, Brazil)loaded with No. 2 Ethibond (Ethicon, Somerville, NJ)from 5 mm of the edge of the glenoid joint. Thecapsule and the subscapularis tendon were sutured bya side-to-side repair with No. 2 Ethibond, the super-ficial layers were then closed, and no drainage wasused. In the immediate postoperative period, all pa-tients were advised to wear a sling for total restrictionof external rotation and abduction.

Repair of Bankart Lesion by Arthroscopy

Bankart lesion repair was performed with a proce-dure described by Snyder,18 with the patient in thelateral decubitus position (repositioned after diagnos-tic arthroscopy in beach-chair position) (Fig 2). Anarthroscopic suture passer (Suture Punch or Spectrum;Linvatec, Largo, FL) was used to suture the labrum

around the edge of the glenoid cavity with 4 � 13 �

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3BANKART LESION TREATMENTAQ: 1

2–mm metal anchors (Hexagon Brasil) loaded withNo. 2 Ethibond from 5 mm of the edge of the glenoidcavity. All patients were advised to wear a sling fortotal restriction of external rotation and abduction.

For both techniques, the number of anchors used foreach repair was decided by each surgeon during theintraoperative procedure.

Postoperative Period

On discharge, all the patients were given nonster-oidal anti-inflammatory drugs (meloxicam, 15 mg/d)for 5 days and painkillers (paracetamol, 750 to 2,250mg/d) where necessary for 7 days. The patients at-tended the outpatient clinic in the first week for ban-

FIGURE 1. (A and B) Open repair of right shoulder. (A, ancho

FIGURE 2. (A and B) Arthroscopic repair of left shoulder, posteri

guide of anchor; U, humerus.)

daging and in the second week for stitch removal. Theother appointments occurred in the fourth and eighthweeks and, afterward, on a monthly basis until the endof the follow-up period.

All the patients were rehabilitated according to thesame protocol. In the first 7 postoperative days, slinguse was maintained continuously and the sling wasonly removed for elbow flexion-extension. From theseventh day on, the patients were advised to maintaindiscontinuous immobilization for 3 more weeks, onlyremoving the sling for active and passive elbow move-ment and passive shoulder movement up to 0° ofexternal rotation and 90° of abduction in the scapularplane, 3 times a day. In the fourth week, immobiliza-

on; C, capsule; G, glenoid; SA, articular surface; U, humerus.)

l view. (G, glenoid; L, labrum [in A]/reattached labrum [in B]; P,

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tion was eliminated, and progressive range of move-ment was gained in all participants. The patients weredischarged from physiotherapy 16 weeks later andwere able to participate in sporting activities 24 weeksafter surgery.

All the participants were examined from 2007 to2008 by physicians (residents under supervision ofboard-certified shoulder surgeons) not directly in-volved in the study. The primary outcome assessedwas the DASH questionnaire validated and translatedinto Portuguese15,16; the final score of the DASHquestionnaire was turned into a percentage by use ofthe following formula: Scoring � [Sum of answersn/n – 1] � 25, where n is the number of completeanswers. The 2 optional modules were not measured.The value obtained was directly proportional to thepercentage of impairment of the limb function.

The University of California, Los Angeles (UCLA)scale19 and the Rowe scale2 were also evaluated assecondary outcomes.

Two evaluators measured the bilateral range ofmovement using the Carci universal goniometer(Carci, São Paulo, Brazil). Elevation and active exter-nal rotation, both in the scapular plane, were measuredby comparison of preoperative and postoperative de-scriptive variables. Internal active rotation was as-sessed before and after surgery by use of part of theConstant functional assessment scale.20 Radiographicexamination was performed in the first postoperativeweek and during the final assessment, including an-teroposterior and axillary views and a lateral view ofthe scapula.

Statistical Method

The variables were summarized by study group andrepresented by the pertinent descriptive statistics:mean, standard deviation, median, minimum and max-imum values, or absolute and relative frequencies(percents). The surgery groups were compared regard-ing the qualitative variables by use of the �2 test orFisher exact test. The Student t test or Mann-Whitneyest was used in the comparison between surgeryroups regarding quantitative variables, according tohe presence of normal distribution in the assessedariables. The Wilcoxon test was used in the compar-son between preoperative and postoperative measuresor each side within each group. The paired t test or

ilcoxon test was used in the comparison of theffected and contralateral sides regarding the quanti-ative variables, according to the occurrence of normal

istribution in the variations between the sides. This s

nalysis was performed in the total sample and forach surgery group separately. A significance level of05 (á � 5%) was used, and the SPSS statisticalrogram for Windows (version 15.0; SPSS, Chicago,L) was run in all the analyses.

All recurrences that required additional interven-ions not included within the protocol were consideredomplications. A need for further intervention or ahange in the initial randomized treatment was con-idered a failure. Patients for whom treatment hasailed, regardless of the reason, were followed up, andhe results were included in the original group, accord-ng to the intention-to-treat principle.

RESULTS

Fifty-six patients who fulfilled the inclusion cri-eria were considered eligible for the study. Ofhese, after the diagnostic arthroscopy, 6 were ex-luded: 3 had SLAP lesion (1 type II and 2 type III),had glenoid bone defect, and 1 had partial-thick-

ess rotator cuff tear (Fig 3). We randomized 50atients for the 2 intervention methods, of whom 42ompleted the final follow-up (25 in open techniqueroup and 17 in arthroscopy group). There was noignificant difference in demographic data betweenhe 2 groups (Table 1). Of the 8 patients (16%) whoere not assessed, 2 died of causes unrelated to the

ntervention and the other 6 quit the study beforehe first month of follow-up without any complica-ions. The mean follow-up period was 37.5 months,anging from 20 to 56 months (Fig 3).

Comparison between groups showed a statisticallyignificant difference in favor of the arthroscopyroup when we assessed the primary outcome, DASHuestionnaire (P � .031), with a mean difference of.57 points (Tables 1 and 2).No significant differences between groups were

een in the secondary outcomes overall. No statisti-ally significant differences were found between theechniques for the UCLA and Rowe scores (P � .999)Table 2). Moreover, no statistically significant differ-nces were found between the techniques for the as-essments of shoulder range of motion of the affectedide in the preoperative and postoperative periodsTable 3).

The 2 study groups did not differ significantly withespect to the number of anchors used during the

urgical interventions (Table 4).

5BANKART LESION TREATMENT

FIGURE 3. Enrollment, assigned intervention, and follow-up.

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Adverse Events

No complications were associated with the use ofthe metal anchors, such as malposition, loosening, ormigration of the implants. One patient in the opengroup presented with wound superficial infection,which demanded a 4-week treatment with antibiotics,but there was no need for a new surgical interventionor treatment change (patient 40).

There were 2 cases of failure in the arthroscopicgroup (patients 12 and 13) and none in the opentechnique group (P � .158). These 2 patients re-ported symptoms of anterior instability with a newtraumatic episode of shoulder dislocation that re-quired additional surgical intervention, with anopen technique.

DISCUSSION

Bankart surgery is the standard of excellence for theepair of the labrum and capsule in the treatment ofnterior shoulder instability.9,11,21-23 On the basis ofevisions of controlled clinical trials, there is no con-lusive evidence to determine which technique isore effective in the surgical treatment of Bankart

esion: open or arthroscopic procedure.12,24 The maincriticism of the arthroscopic method concerns the sig-nificant recurrence rate of shoulder dislocations com-pared with the open technique. However, this findingwas based on comparisons of the open technique usinganchors versus the arthroscopic treatment usingtransglenoid suture fixation or other fixation tech-niques (“tacks”) in studies with different method de-signs with a reduced number of patients.

Our study was aimed to assess the effectiveness ofthe open and arthroscopic methods in the treatment of

TABLE 1. Demographic Data

VariableOpen

(n � 25)Arthroscopic

(n � 17) Comparison

Mean age (SD) (yr) 30.8 (5.6) 27.5 (5.4) P � .065Right side (%) 12 (48%) 9 (52.9%) P � .753Arm dominance (%) 22 (88.0%) 16 (94.1%) P � .635Mean time from first

dislocation tosurgery (SD) (mo) 62.9 (55.0) 45.7 (41.8) P � .424

Mean no. ofepisodes ofdislocation (SD) 16.3 (12.1) 10.8 (6.4) P � .160

Male gender (%) 21 (84.0) 16 (94) P � .632

Bankart lesion in traumatic anterior shoulder instabil-

ity. The calculation of the sample size was based onthe main outcome, which was the assessment of upperlimb disability with the DASH scale, including a totalof 50 patients. There are 2 studies with a similardesign comparing both procedures, which included 60and 64 patients.7,25

Randomization was performed with computer soft-are, and the results were kept in opaque and sealed

nvelopes, which were only opened at the moment ofhe main intervention. As for our sampling group, webserved that the inclusion and exclusion criteria al-owed the allocation of 2 homogeneous groups thatad only isolated Bankart lesions. However, in thetudy of Bottoni et al.,25 the criteria used were notdequate, resulting in a heterogeneous sample, whichay have influenced the results.Diagnostic arthroscopy was used as an inclusion

riterion because it is the gold standard for the diag-osis of intra-articular injury. Therefore we ensuredhe presence of isolated Bankart lesions, as has beenerformed in the study of Fabbriciani et al.7 but not inhe study of Bottoni et al.,25 who used preoperative

agnetic resonance imaging in all patients, conclud-ng that sensitivity and specificity are not entirelyeliable.

We have selected isolated Bankart lesions that areot associated with glenoid bone defect and/or engag-ng Hill-Sachs lesion, because both lesions have aegative impact on the outcome of surgical treatmentf Bankart lesions, increasing failure rates.13 These 2xclusion criteria adopted in our study were not usedn the study of Bottoni et al.,25 and Fabbriciani et al.7

only excluded patients with glenoid bone defect,which may have influenced their findings. SLAP le-sions and rotator cuff tears were also excluded in our

TABLE 2. DASH, UCLA, and Rowe Scores

Endpoint

Technique

ComparisonOpen

(n � 25)Arthroscopic

(n � 17)

DASH P � .031Mean (SD) 4.22 (5.8) 2.65 (7.3)Median 1.66 0Range 0-20.83 0-24.16

UCLA

P � .999Good/excellent (%) 23 (92.0) 16 (94.1)Fair/poor (%) 2 (8.0) 1 (5.9)

RoweExcellent (%) 20 (80) 13 (76.5)Good (%) 5 (20) 1 (5.9)

P � .999Fair (%) 0 3 (17.6)

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study, because we did not want to consider any addi-tional known factor that might cause pain or restric-tion of movement in the postoperative period. Fabbri-ciani et al. also excluded SLAP and rotator cufflesions, whereas Bottoni et al. did not describe thesecriteria.

The postoperative period is an important factor re-lated to recurrence of instability. According to theliterature, the period suggested for the assessment ofinstability recurrence is approximately 2 years. In ourstudy the mean follow-up period was 37 months,greater than the follow-up period in the studies ofFabbriciani et al.7 and Bottoni et al.25 of 24 monthsnd 29 months, respectively.

Regarding the surgical techniques discussed in ourtudy, the open technique was the modified Bankartrocedure described by Matsen et al.,17 the same onesed in the study of Fabbriciani et al.7 However,

Bottoni et al.25 performed capsuloplasty as describedby Neer and Foster26 in association with Bankartepair, which may generate an additional mecha-ism of shoulder stabilization or even postoperativeestriction of movements. In our study we used therthroscopic technique described by Snyder,18

which is similar to the open technique, because itpromotes the reattachment of the labrum in the edgeof the glenoid without causing excessive tighteningof the joint capsule, as in the study of Fabbriciani etal. We believe that this surgical approach can becompared with the open Bankart technique used inour study. Bottoni et al. used the arthroscopic pro-

TABLE 3. Shoulder Ran

VariableArc of Movement

Before Interventio

Elevation (°)Open technique 167.6 (17.0)Arthroscopic technique 169.0 (21.7)Comparison

External rotation (°)Open technique 63.2 (13.9)Arthroscopic technique 74.5 (11.4)Comparison

Internal rotation (°)Open technique 8.9 (2.1)Arthroscopic technique 8.7 (1.9)Comparison

NOTE. Data are presented as mean/standard d

cedure described by Bottoni and Arciero,27 stress-

ng the tightening of the capsule associated withuture through the glenoid labrum.

The DASH scale, our primary outcome, is describeds a superior psychometric assessment tool comparedith other scales such as the American Shoulder andlbow Surgeons assessment, Shoulder Pain and Dis-bility Index, and Simple Shoulder Test.28 Althoughrthroscopy showed better results in the endpointASH (P � .031), in absolute values, the differenceas less than 10 points, which means not clinically

elevant.28 This outcome cannot be compared withimilar results in the literature, because there was nonalysis of the DASH score in the studies of Fabbri-iani et al. and Bottoni et al.

Regarding the assessments using the UCLA andowe shoulder scores, there was no significant dif-

erence between the open and arthroscopic groups.oncerning the results of functional assessments inther studies, Bottoni et al.25 used the Single As-essment Numeric Evaluation, UCLA, and Simplehoulder Test scales to perform the functional com-arison of the arthroscopic and open groups, as wells the Western Ontario Shoulder Instability scale

TABLE 4. Number of Suture Anchors

No. of Anchors (%) Open Arthroscopic Comparison

1 1 (4.0%) 2 (11.8%) P � .3752 17 (68.0%) 7 (41.2%)3 7 (28.0%) 7 (41.2%)

Motion of Affected Side

sessment

Comparisonrc of Movementfter Intervention Difference

165.8 (19.7) –1.8 (26.4) P � .936174.8 (8.2) 5.8 (17.2) P � .310

P � .673

59.9 (14.6) �3.3 (11.9) P � .07170.8 (17.2) �3.6 (14.4) P � .155

P � .969

8.8 (2.0) 0.1 (2.3) P � .8808.8 (1.7) �0.1 (1.8) P � .860

P � .970

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for assessing shoulder stability, and they found nostatistically significant differences between thegroups. Fabbriciani et al.7 used the Constant shoul-

er score for functional assessment and Rowe stan-ard rating scale.We assessed range of motion as a secondary out-

ome. For the evaluation of internal rotation, we chosehe criteria of the Constant shoulder score and as-igned a numeric value to the position arm.20 Con-erning the evaluation of this variable, we used exam-ners blinded to the groups to reduce bias, as in thetudy by Bottoni et al.25 Our results did not showignificant differences between the scapular plane ab-uction, internal rotation, and external rotation, whichs consistent with the findings of Bottoni et al. Nev-rtheless, Fabbriciani et al.7 found statistically signif-

icant values favorable to the arthroscopic techniqueusing the Constant shoulder score.

Regarding the complications related to surgicaltechniques, 1 patient in the open group had a surgicalwound infection and needed antibiotic therapy. Nopatient in the arthroscopic group had any complica-tion. The study of Fabbriciani et al.7 reported noomplication in any of the groups. On the other hand,ottoni et al.25 reported a late complication of the

open technique, which led to rupture of the subscap-ularis tendon. Other studies, such as that of Green andChristensen,6 reported a greater number of complica-tions with open Bankart surgery compared with thearthroscopic procedure. No complication associatedwith the type of anchor was reported in our study.Likewise, Fabbriciani et al. used metal anchors with-out any complication, and Bottoni et al. used bioab-sorbable anchors without any complications. No dif-ferences in outcomes of interventions for treatingshoulder instability were seen whether absorbable ornonabsorbable anchors were used.29,30 Regarding theumber of anchors used, no difference was shownetween the open and arthroscopic groups, a resultimilar to that found in the study of Bottoni et al.; thisas not reported in the study of Fabbriciani et al.pparently, there is equal demand between the tech-iques.Concerning failures, none was detected in the open

echnique; however, 2 anterior instability recurrencesere observed in the arthroscopic group (P � .158).he 2 instability recurrences were associated with aew trauma with shoulder dislocation, in contactports, with only 1 case of dislocation until the end ofur follow-up. The profile of the activity of eachatient is directly related to the recurrence because of

he exposure to the risk of further trauma. There is s

ontroversy in the literature regarding the indicationsor the arthroscopic technique in the treatment ofatients who play contact sports. However, we believehat postsurgical recurrence in sports is because of theccurrence of a new trauma, which may cause dislo-ation in any of the shoulders, whether operated on orot.13

Fabbriciani et al.7 and Bottoni et al.25 described nosignificant difference in instability recurrence betweenopen and arthroscopic techniques.

We included all the standards of detachment of theglenoid labrum because of the various episodes ofdislocations and also because of the long period be-tween the first dislocation and the surgical interven-tion, which has made it difficult to perform the stan-dard diagnosis of these lesions. Habermeyer et al.31

assessed the evolution of intra-articular lesion in theinstability of the shoulder using arthroscopy. Theyconcluded that relapses have progressively damagedthe stabilizing structures. However, they did not cor-relate such recurrent events with Bankart variants,such as the subperiosteal detachment of the glenoidlabrum (anterior labroligamentous periosteal sleeveavulsion). Although some articles have describedhigher failure-of-treatment rates in patients with ante-rior labroligamentous periosteal sleeve avulsion vari-ation, controlled prospective studies are needed, be-cause various factors are involved in these failures.32

One weakness of our study was sampling loss in theostoperative follow-up period of 3 patients in thepen group and 5 patients in the arthroscopic group.f the 5 non-evaluated patients in the arthroscopicroup, 2 died of causes unrelated to the treatment (1ied of mesenteric vessel thrombosis at 16 monthsostoperatively and 1 died of a gunshot wound) and 3id not attend the final evaluation appointment, whichay have affected our results because there has beenmore significant sampling loss in the arthroscopic

roup (Fig 3).Our study had other sources of bias. First, the study

esign did not permit blinding of participants, sur-eons, and outcome assessors; although failure oflinding can have a serious effect on study outcomes,e were unable to perform blinding. Second, 4 sur-eons performed all surgical interventions; despite theact that they are board-certified shoulder surgeonsith more than 5 years’ experience, this might be a

ause of performance bias and recording. Third, thistudy was slightly underpowered. Finally, we alsoave reservations about the DASH score; although itay have been validated for use in a number of

ettings, this score may not be specific for use as an

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9BANKART LESION TREATMENT

outcome in shoulder instability, most likely because itrefers to the whole upper limb.

CONCLUSIONS

On the basis of this study, the open and arthroscopictechniques were effective in the treatment of traumaticanterior shoulder instability. The arthroscopic tech-nique showed a lower index of functional limitation ofthe upper limb, as assessed by the DASH question-naire; this, however, was not clinically relevant.

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2. Rowe CR, Patel D, Southmayd WW. The Bankart procedure:A long-term end-result study. J Bone Joint Surg Am 1978;60:1-16.

3. Rosenberg BN, Richmond JC, Levine WN. Bankart repair foranterior instability of the shoulder. Long–term outcome.J Bone Joint Surg Am 1998;80:1083-1084.

4. Pagnani MJ. Open capsular repair without bone block forrecurrent anterior shoulder instability in patients with andwithout bony defects of the glenoid and/or humeral head. Am JSports Med 2008;36:1805-1812.

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6. Green MR, Christensen KP. Arthroscopic versus open Bankartprocedures: A comparison of early morbidity and complica-tions. Arthroscopy 1993;9:371-374.

7. Fabbriciani C, Milano G, Demontis A, Fadda S, Ziranu F,Mulas PD. Arthroscopic versus open treatment of Bankartlesion of the shoulder: A prospective randomized study. Ar-throscopy 2004;20:456-462.

8. Freedman KB, Smith AP, Romeo AA, Cole BJ, Bach BR Jr.Open Bankart repair versus arthroscopic repair with transgle-noid sutures or bioabsorbable tacks for recurrent anterior in-stability of the shoulder: A meta-analysis. Am J Sports Med2004;32:1520-1527.

9. Mohtadi NG, Bitar IJ, Sasyniuk TM, Hollinshead RM, HarperWP. Arthroscopic versus open repair for traumatic anteriorshoulder instability: A meta-analysis. Arthroscopy 2005;21:652-658.

0. Hobby J, Griffin D, Boileau P. Is arthroscopic surgery forstabilisation of chronic shoulder instability as effective as opensurgery? A systematic review and meta-analysis of 62 studiesincluding 3044 arthroscopic operations. J Bone Joint Surg Br2007;89:1188-1196.

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2. Petrera M, Patella V, Patella S, Theodoropoulos J. A meta-analysis of open versus arthroscopic Bankart repair usingsuture anchors. Knee Surg Sports Traumatol Arthrosc 2010;18:1742-1747.

3. Burkhart SS, De Beer F. Traumatic glenohumeral bone defectsand their relationship to failure of arthroscopic Bankart re-pairs: Significance of the inverted-pear glenoid and the hu-meral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677-

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