Arthroscopic Latarjet yields better union and

prevention of instability compared to arthroscopic bony

Bankart repair in shoulders with recurrent anterior
instability: a systematic review
Anselme Billaud, Laurent Baverel, Pierre Metais, Floris van Rooij, Ankitha
Kumble, Guillaume Villatte, Edouard Dejour, Geoffroy Nourissat

To cite this version:

Anselme Billaud, Laurent Baverel, Pierre Metais, Floris van Rooij, Ankitha Kumble, et al.. Arthro-
scopic Latarjet yields better union and prevention of instability compared to arthroscopic bony
Bankart repair in shoulders with recurrent anterior instability: a systematic review. Knee Surgery,
Sports Traumatology, Arthroscopy, 2023, 31 (12), pp.5994-6005. �10.1007/s00167-023-07655-x�. �hal-
04611204�

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1 Title: Arthroscopic Latarjet yields better union and prevention of instability compared to

2 arthroscopic bankart repairs in shoulders with recurrent anterior instability: a systematic

3 review
 4 Abstract

5 Purpose: To determine whether arthroscopic Latarjet procedure arthroscopic Latarjet or

6 arthroscopic bony Bankart repair arthroscopic bony Bankart repair provide better outcomes in

7 terms of rates of recurrent instability, non-union and complications, as well as clinical scores

8 and range of motion.

9 Methods: An electronic literature search was performed using PubMed, Embase®, and

10 Cochrane databases, applying the following keywords: “Arthroscopic bony bankart” OR

11 “Arthroscopic osseous bankart” AND “Arthroscopic Latarjet” OR “Arthroscopic coracoid

12 Bone block”.

13 Results: The systematic search returned 1,465 records, of which 29 were included

14 (arthroscopic bony Bankart repair, n=16; arthroscopic Latarjet, n=13). 37 datasets were

15 included for data extraction, on 1483 shoulders. Compared to arthroscopic Latarjet,

16 arthroscopic bony Bankart repair had significantly higher instability rates (0.14; CI, 0.10–

17 0.18; vs 0.04; CI, 0.02–0.06), significantly lower union rates (0.63; CI, 0.28–0.91 vs 0.98; CI,

18 0.93–1.00), and significantly lower pain on VAS (0.42; CI, 0.17–0.67 vs 1.17; CI, 0.96–

19 1.38). There were no significant differences in preoperative glenoid bone loss, follow-up,

20 complication rate, ROWE score, ASES score, external rotation, and anterior forward

21 elevation between arthroscopic Latarjet and arthroscopic bony Bankart repair.

22 Conclusion: Compared to arthroscopic Latarjet, arthroscopic bony Bankart repair results in

23 significantly (i) higher rates of recurrent instability (14% vs 4%), (ii) lower union rates (63%

24 vs 98%), but (iii) slightly lower pain on VAS (0.45 vs 1.17). There were no differences in

25 complication rates, clinical scores, or postoperative ranges of motion.

26 Level of Evidence: Level IV

27 Keywords: Arthroscopic Latarjet procedure, bony Bankart procedure, anterior instability,

28 outcomes
29 Introduction

30 Anterior shoulder instability often requires surgical treatment, particularly in young athletes

31 who wish to resume sports [3,46,50]. The most common surgical treatments involve either

32 labral or capsular repair in shoulders with no glenoid defects [34,51], or bone-block

33 procedures in shoulders with glenoid defects [13,26,35]. The Latarjet technique is among the

34 most popular bone-block procedures, as it proved effective at preventing recurrent

35 dislocations [1,2,12,21,25,27,39] whether performed as an open or an arthroscopic procedure

36 [15,33]. The Latarjet technique is however technically demanding and therefore has a

37 considerable learning curve and requires alteration of native scapular anatomy [5,9,15].

38

39 More recently, arthroscopic bony Bankart repair arthroscopic bony Bankart repair[49] was

40 introduced as a less invasive alternative to arthroscopic Latarjet, to treat anterior shoulder

41 instability with traumatic glenoid defects, where the bone fragment is still present and could

42 be sutured back onto the glenoid [4]. While arthroscopic bony Bankart repair demonstrated

43 satisfactory bone union rates, it is associated with higher rates of recurrent instability

44 compared to arthroscopic Latarjet [6,39,52,54], and may be insufficient to treat shoulders

45 with irreparable ligamentous damage, attritional glenoid bone loss, or major bone

46 deficiencies [15].

47

48 There is no consensus on the optimal treatment for recurrent anterior shoulder instability with

49 traumatic glenoid defects. Therefore, the purpose of this study is to determine whether

50 arthroscopic Latarjet or arthroscopic bony Bankart repair provide better outcomes for this

51 population in terms of rates of recurrent instability, non-union and complications, as well as

52 clinical scores and range of motion.

53 Materials and Methods

54 The protocol for this systematic review was submitted to PROSPERO prior to

55 commencement (registration number BLINDED) and conforms to the principles outlined in

56 the handbook of the Cochrane Collaboration [19], along with the guidelines established by

57 the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) [37].

58

59 Search strategy

60 The authors conducted a structured electronic literature search on 06 July 2022 using the

61 PubMed, Embase®, and Cochrane Central Register of Controlled Trials databases, applying

62 the following keywords: “Arthroscopic bony bankart” OR “Arthroscopic osseous bankart”

63 AND “Arthroscopic Latarjet” OR “Arthroscopic coracoid Bone block”. The full search

64 strategy is presented in Appendix I. The search was limited to articles published between

65 2002 and 2022. After removal of duplicate records, each of two researchers (BLINDED)

66 screened the titles and abstracts to determine the suitability for the review using the following

67 predefined eligibility criteria:

68

69 Inclusion criteria

70 - Comparative or non-comparative studies on patients with recurrent anterior shoulder

71 instability that underwent either primary arthroscopic Latarjet or primary arthroscopic

72 bony Bankart repair with or without adjuvant procedures

73 - Studies that measured preoperative glenoid bone loss using computed tomography

74 (CT) scans

75 - Studies that report pre- and post-operative clinical outcomes in terms of, recurrence of

76 instability, non-union, complication rates, range of motion, or clinical scores

77
 78 Exclusion criteria:

79 - Narrative or systematic reviews, case reports, expert opinions, editorials, letters to

80 editors, computer simulations, cadaver or laboratory studies

81 - Studies published in languages other than English, French, German, Italian, Spanish,

82 and Dutch to avoid translation errors.

83

84 Study selection

85 Studies that met the eligibility criteria during title and abstract screening underwent full-text

86 screening by two researchers (BLINDED) and any disagreement was first discussed between

87 the researchers, and if required, a third researcher (BLINDED) resolved any disagreement.

88 The reference lists of studies for full text review were searched, and an expert (BLINDED)

89 was consulted to identify further relevant studies that may not have been captured by the

90 database searches.

91

92 Data extraction and quality assessment

93 Data extraction was performed by two researchers (BLINDED) independently and their

94 results were compared to ensure accuracy. Where there was disagreement in the documented

95 value, the true value was ascertained by simultaneous review of the data in question by both

96 researchers. The following information was extracted from the included studies; author(s),

97 journal, year of publication, level of evidence, country where study was performed, conflicts

98 of interest and funding declaration. Furthermore, the following clinical data was extracted:

99 type of surgery, subgroup size, sex, age, preoperative glenoid bone loss, union rates (instead

100 of non-union rates which were inconsistently defined and reported), recurrent instability rates

101 (defined as recurrence of subluxation and/or dislocation), post-operative complication rates,

102 range of motion (ROM; ER1, arm at 0° of abduction; ER2, arm at 90° of abduction; AFE,

103 anterior forward elevation), clinical scores, and pain on VAS scale.

104

105 Methodological quality of the eligible studies was assessed by two researchers (BLINDED)

106 according to the Joanna Briggs Institute (JBI) checklist, to appraise the reporting quality (10

107 items). Where there was disagreement between the researchers, consensus was achieved by

108 discussion and review.

109

110 Statistical analysis

111 When available in the original articles, outcomes were tabulated: continuous outcomes were

112 reported as means, standard deviations, and ranges, while categorical outcomes were reported

113 as proportions. Pooled estimates were calculated if mean and standard deviations were

114 available for least 3 studies reported. When the standard deviation was not reported, the range

115 was used to calculate standard deviation using a method outlined by Hozo et al.[22].

116 Heterogeneity was evaluated by visual inspection of forest plots and using the I2 statistic and

117 its connected χ2 test, to provide a measure of the degree of inconsistency across studies.

118 Pooled estimates of raw means and their 95% confidence interval (CI) were calculated using

119 a random-effects model framework. Pooled estimates of proportions and their 95%

120 confidence intervals (CI) were calculated via Freeman-Tukey double arcsine transformation

121 using inverse-variance weighting within a random-effects model framework. P-values <0.05

122 were considered statistically significant. Statistical analyses were performed using R version

123 4.1.3 (R Foundation for Statistical Computing, Vienna, Austria) using the meta package.
124 Results

125 The systematic search returned 1,465 records, of which 563 were duplicates, leaving 902 for

126 title and abstract screening (Figure 1). A total of 786 studies were excluded by examining

127 their titles and/or abstracts because: 500 were not relevant, 223 were editorials/conference

128 proceedings etc., 29 were reviews, 17 were published before 2002, and 17 were published in

129 languages other than those defined in the exclusion criteria. A further 87 studies were

130 excluded after full-text review. This left 29 eligible studies,[1,7,8,11,14,16-18,23,24,29-

131 32,38,40-45,47,48,53,55-59] of which 16 assessed arthroscopic bony Bankart repair, 13

132 assessed arthroscopic Latarjet (Table 1 and 2). All studies reported preoperative glenoid bone

133 loss: 21 reported mean preoperative glenoid bone loss, of which 4 created subgroups of

134 glenoid bone loss and reported the mean loss of each subgroup, while 8 used a threshold of

135 glenoid bone loss as a part of their inclusion criteria. Of the 29 eligible studies, 37 datasets

136 were included for data extraction, with a total of 1,483 shoulders (arthroscopic bony Bankart

137 repair, n=874; AL, n=609) (Table 3 and 4). Of the 37 included datasets, 12 datasets reported

138 on concomitant Hill-Sachs (arthroscopic bony Bankart repair, n=7 and arthroscopic Latarjet,

139 n=5) lesions.

140

141 Quality assessment

142 Of the 29 eligible studies, 2 were prospective and 27 were retrospective. Of the 29 studies, 3

143 did not report criteria for inclusion and 2 did not specify the presenting sites demographic

144 information. Furthermore, it was unclear in 4 studies whether the study had complete

145 inclusion of participants. Overall, all included studies had good to excellent scored according

146 to the JBI checklist (Table 5).

147

148 Preoperative glenoid bone loss

149 Of the 37 included datasets, preoperative glenoid bone loss was reported as part of their

150 inclusion criteria in 7 and was reported as a mean in 26 datasets (arthroscopic bony Bankart

151 repair, n=19; arthroscopic Latarjet, n=7). There was no significant difference in mean

152 preoperative glenoid bone loss between shoulders treated by arthroscopic bony Bankart repair

153 (17.6%; CI, 13.7–21.6; I2=99%) or arthroscopic Latarjet (18.9%; CI, 13.5–24.3; I2=98%)

154 (Figure 2).

155

156 Follow-up

157 Of the 37 included datasets, mean follow-up was reported in 24 (arthroscopic bony Bankart

158 repair, n=13; arthroscopic Latarjet, n=11). There was no significant difference in mean

159 follow-up between shoulders treated by arthroscopic bony Bankart repair (49.3 months; CI,

160 27.9–70.8; I2=100%) or arthroscopic Latarjet (29 months; CI, 20.7– 37.3; I2=99%).

161

162 Recurrent instability

163 Of the 37 included datasets, rates of recurrent instability were reported in 19 (arthroscopic

164 bony Bankart repair, n=13; arthroscopic Latarjet, n=6). There was a statistically significant

165 higher rate of instability following arthroscopic bony Bankart repair (0.14; CI, 0.10–0.18;

166 I2=49%) compared to arthroscopic Latarjet (0.04; CI, 0.02–0.06; I2=0%) (Figure 3).

167

168 Union

169 Of the 37 included datasets, union was reported in 14 (arthroscopic bony Bankart repair, n=5;

170 arthroscopic Latarjet, n=9). All studies assessed union using postoperative CT scans, and

171 there was a statistically significant lower union rate following arthroscopic bony Bankart

172 repair (0.63; CI, 0.28–0.91; I2=96%) compared to arthroscopic Latarjet (0.98; CI, 0.93–1.00;

173 I2=70%) (Figure 4).

174

175 Postoperative complications

176 Of the 37 included datasets, complication rates were reported in 15 (arthroscopic bony

177 Bankart repair, n=3; arthroscopic Latarjet, n=12), of which 3 reported rates instead of

178 absolute values [23,57]. There was no statistical difference in complication rate following

179 arthroscopic bony Bankart repair (0.01; CI, 0.00–0.07; I2=0%) compared to arthroscopic

180 Latarjet (0.03; CI, 0.00–0.06; I2=47%) (Figure 5).

181

182 Clinical scores

183 There were no significant differences between arthroscopic bony Bankart repair and

184 arthroscopic Latarjet, in terms of ROWE score (92.78 vs 92.47), and ASES score (94.26 vs

185 92.16). However, arthroscopic bony Bankart repair demonstrated significantly lower pain on

186 VAS (0.42) compared to arthroscopic Latarjet (1.17; p<0.01).

187

188 Range of motion

189 There were no significant differences between arthroscopic bony Bankart repair and

190 arthroscopic Latarjet, in terms of ER1 (59.5° vs 57.26°), and AFE (167.93° vs 170.90°).
191 Discussion

192 The most important findings of this meta-analysis are that, compared to arthroscopic Latarjet,

193 arthroscopic bony Bankart repair results in significantly (i) higher rates of recurrent

194 instability (14% vs 4%), (ii) lower union rates (63% vs 98%), but (iii) slightly lower pain on

195 VAS (0.45 vs 1.17). There were however no significant differences in complication rates,

196 clinical scores, or postoperative ranges of motion. The null hypothesis that the two

197 procedures would result in comparable outcomes is therefore refuted. The clinical relevance

198 of these findings is that, while arthroscopic bony Bankart repair demonstrated comparable

199 clinical scores to arthroscopic Latarjet, the latter might be more suitable in patients prone to

200 recurrent instability or non-union. It is worth noting, however, that the present meta-analysis

201 did not account for the surgeon experience and learning curves, which should also be

202 considered when choosing the surgical technique.

203

204 The present systematic review included studies that had good to excellent scores according to

205 the JBI checklist. A previous systematic review by Longo et al.[36] compared outcomes of all

206 surgical treatments for traumatic anterior glenohumeral instability with glenoid and/or

207 humeral bony defects. Longo et al.[36] found that shoulders with glenoid bone loss <25%

208 were most frequently treated with arthroscopic Bankart repair (50%) or arthroscopic bony

209 Bankart repair (32%), while shoulders with glenoid bone loss >25% were most frequently

210 managed by open reconstruction with bone graft (37%), arthroscopic Bristow procedure

211 (26%), or open Latarjet procedure (OLP) (22%). The present meta-analysis found no

212 significant difference in mean preoperative glenoid bone loss between shoulders treated with

213 arthroscopic bony Bankart repair (17.6%; CI, 13.7–21.6) versus arthroscopic Latarjet (18.9%;

214 CI, 13.5–24.3).However, it remains unclear whether the choice of procedure should be based

215 on the extent of glenoid bone loss, or rather on the size of the remaining bone fragment
216 present that could be sutured back onto the glenoid. It is worth noting that arthroscopic bony

217 Bankart repair may be insufficient to treat shoulders with irreparable ligamentous damage,

218 attritional glenoid bone loss, or major bone deficiencies [15], where bone block procedures

219 may be the only treatment option. A recent systematic review by Hurley et al.[28] compared

220 outcomes of ABR alone versus ABR with remplissage versus OLP, to treat anterior shoulder

221 instability in patients with concomitant Hill-Sachs lesions. Hurley et al.[28] found higher

222 rates of recurrent instability following ABR alone (16.8%) compared to OLP (7.0%) and

223 ABR with remplissage (3.2%). A study by Horinek et al. [20] compared OLP with ABR with

224 remplissage, for anterior shoulder instability and found no difference in terms of clinical

225 scores, return to sport, and satisfaction. In the present meta-analysis, only one study

226 performed arthroscopic bony Bankart repair with remplissage (in 11 of 312 patients) [47] but

227 did not report the outcomes of this subgroup. Furthermore, out of the 29 included studies in

228 the present meta-analysis, Hill-Sachs lesions were reported in 15 studies, and their prevalence

229 ranged from 24% to 100%. It was not possible to perform a subgroup analysis of the

230 outcomes of this pathology as the type of Hill-Sachs lesion was not consistently reported,

231 which could affect the rate of recurrent instability [10,36].

232

233 The results of the present meta-analysis should be interpreted with the following limitations

234 in mind. All included studies were case series, although the level of quality was good to fair.

235 Furthermore, the thresholds of glenoid bone loss reported were heterogenous across studies

236 which makes it difficult to determine whether the choice for arthroscopic bony Bankart repair

237 or arthroscopic Latarjet should be based on the extent of preoperative glenoid bone loss. This

238 meta-analysis did not evaluate Hill-Sachs lesions which could have affected recurrent

239 instability rates [10,36] as the specific lesions were not consistently reported. Additionally,

240 there is need for a more standardised method of reporting outcomes as a great number of
241 different clinical scores were reported, making it difficult to quantitively compare studies.

242 Finally, it is worth noting that, while there was no statistically significant difference in

243 follow-up between the two techniques, the mean follow-up for arthroscopic bony Bankart

244 repair was almost 2 years longer than for arthroscopic Latarjet, which could introduce bias in

245 the comparisons.

246

247 Conclusion

248 This systematic review and meta-analysis found that, compared to arthroscopic Latarjet,

249 arthroscopic bony Bankart repair results in significantly (i) higher rates of recurrent

250 instability (14% vs 4%), (ii) lower union rates (63% vs 98%), but (iii) slightly lower pain on

251 VAS (0.45 vs 1.17). There were however no significant differences in complication rates,

252 clinical scores, or postoperative ranges of motion.

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383 39. Murphy AI, Hurley ET, Hurley DJ, Pauzenberger L, Mullett H (2019) Long-term
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454

455
456 Figure legend

457 Figure 1: Flowchart of study inclusion

458 Figure 2: Forest plot on glenoid defect size

459 Figure 4: Forest plot on recurrent instability

460 Figure 5: Forest plot on union

461 Figure 6: Forest plot on postoperative complications

462

463 Supplementary material:

464 Figure 1: Forest plot on follow-up

465 Figure 2: Forest plot on ROWE score

466 Figure 3: Forest plot on ASES score

467 Figure 4: Forest plot on pain on VAS

468 Figure 5: Forest plot on external rotation 1

469 Figure 6: Forest plot on active forward elevation

470 Appendix 1: Search strategy

471
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474 F2
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479 F4

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482 F5
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485 T1

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487 T2
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489 T3

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493 T5
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