Remaining Large Bone Fragment of a Bony Bankart Lesion in Shoulders With a Subcritical Glenoid Defect: Association With Recurrent Anterior Instability

Abstract

Background:

A preoperative glenoid defect of 13.5% or larger is recognized as a subcritical glenoid defect at arthroscopic Bankart repair (ABR) for collision/contact athletes or military personnel.

Purpose:

To clarify the prevalence and size of remaining bone fragments in shoulders with a subcritical glenoid defect at recurrent anterior instability and to investigate the influence on postoperative recurrence after ABR for younger competitive athletes.

Study Design:

Cohort study; Level of evidence, 4.

Methods:

The study included 96 shoulders with recurrent instability that underwent ABR between July 2011 and March 2018 for shoulders with a subcritical glenoid defect. The patients were divided into 2 groups according to the glenoid defect size (13.5%-<20%, medium; ≥20%, large). The bone fragment size in each defect group was retrospectively investigated and classified into 4 groups (no, 0%; small, >0%-<5%; medium, 5%-<10%; large, ≥10%). The postoperative recurrence rate for each combination of glenoid defect size and bone fragment size was investigated for competitive athletes aged <30 years. The fragments, when present, were repaired to the glenoid.

Results:

The glenoid defect size was 13.5%-<20% in 60 shoulders (medium defect group) and ≥20% in 36 shoulders (large defect group). The mean bone fragment size was 6.7% ± 5.1% and 8.9% ± 4.9%, respectively (P = .042). In the medium defect group, there were 15 shoulders (25%) without a bone fragment, 6 shoulders (10%) with a small fragment, 23 shoulders (38.3%) with a medium fragment, and 16 shoulders (26.7%) with a large fragment. In the large defect group, the respective numbers were 2 shoulders (5.6%), 6 shoulders (16.7%), 14 shoulders (38.9%), and 14 shoulders (38.9%). A medium or large bone fragment was more common in the large defect group (P = .252). Among 64 younger competitive athletes who underwent ABR with a minimum of 2 years of follow-up, postoperative recurrence was recognized in 7 of 38 (18.4%) athletes in the medium defect group, but it was not recognized in any of the 26 athletes in the large defect group (P = .036). Postoperative recurrence was recognized in 4 of 12 (33.3%) athletes with a small fragment or no fragment and in 3 of 52 (5.8%) athletes with a medium or large fragment (P = .019).

Conclusion:

A larger bone fragment frequently remained in shoulders with a subcritical glenoid defect at recurrent instability. The postoperative recurrence rate after ABR for younger competitive athletes was low when a remaining larger bone fragment was repaired.

Keywords

recurrent anterior instability subcritical glenoid defect remaining bone fragment bony Bankart lesion arthroscopic Bankart repair

In 2003, Sugaya et al²² used 3-dimensional reconstructed computed tomography (3D-CT) to investigate the characteristics of the anterior glenoid rim structure in shoulders with recurrent anterior instability; the investigators found a bony Bankart lesion (fragment type) in 50% of the shoulders but found no bone fragment, despite the presence of a glenoid defect (erosion or compression fracture type) in 40% of shoulders. Burkhart and De Beer³ considered that patients with a significant bony defect, such as an inverted pear glenoid, were not candidates for arthroscopic Bankart repair (ABR). Other investigators have suggested that a preoperative glenoid defect of 20% to 25% was the critical size at which ABR should generally be avoided.^9,14,25 Several methods of managing such a large glenoid defect have been discussed, including bone grafting.^1,11,24 Shaha et al²¹ investigated clinical outcomes in active duty military personnel and reported that a preoperative glenoid defect of 13.5% was an appropriate threshold for “subcritical” bone loss, which led to a clinically significant worsening in the Western Ontario Shoulder Instability Index scores consistent with an unacceptable outcome. Accordingly, a glenoid defect of 13.5% or larger has become accepted as the definition of a large defect.^{4,8,12,13,26,27}

Regarding the management of large glenoid defects, Boileau et al² and Mologne et al¹⁶ reported that the risk of postoperative recurrence was significantly increased when a bone fragment was not present. In contrast, Sugaya et al²³ reported that arthroscopic repair of bony Bankart lesions (arthroscopic bony Bankart repair; ABBR) was successful even in patients with a chronic glenoid defect because most of the bone fragments were preserved. Kitayama et al¹⁰ later studied the morphologic characteristics of the glenoid rim after ABBR and reported that these characteristics had normalized in all patients after 5 to 8 years. Nakagawa et al¹⁹ found that when postoperative union of the bone fragment was achieved after ABBR, the postoperative recurrence rate was significantly lower and that the glenoid rim morphologic characteristics became closer to normal because the united bone fragment was frequently enlarged via remodeling.

When deciding on the appropriate surgery, surgeons generally consider only the size of a critical glenoid defect, which is determined on the basis of biomechanical data,^9,25 and they do not include factors such as possible bone union from remaining bone fragments or increased size due to remodeling. Although information regarding the prevalence and size of remaining bone fragments in shoulders with a glenoid defect is very important to predict the prognosis after ABR, these factors are still unclear. In shoulders with a small glenoid defect, a bone fragment might not be present when a glenoid defect was formed as a compression fracture, whereas in shoulders with a large glenoid defect, such cases seem to be quite rare.⁶ Thus, in the present study, we decided to include only shoulders with a large glenoid defect. The purposes of the present study were to clarify the prevalence and size of bone fragments in shoulders with a subcritical glenoid defect (restricted to a glenoid defect of ≥13.5%) at recurrent instability and to investigate the influence on the postoperative recurrence after ABR for younger competitive athletes. We hypothesized that relatively large bone fragments remain in shoulders with a subcritical glenoid defect even at recurrent instability and contribute to lower recurrence rates after ABR for younger competitive athletes with a subcritical glenoid defect.

Methods

This was a retrospective investigation of prospectively collected clinical data, and institutional review board approval was obtained. We included consecutive patients with recurrent anterior instability who underwent ABR between July 2011 and March 2018 for shoulders with a subcritical glenoid defect (≥13.5%). All patients provided informed consent.

The study excluded shoulders without a glenoid defect, shoulders with a glenoid defect <13.5%, shoulders with primary instability, shoulders that underwent ABR combined with the open Bristow procedure (B&B), shoulders that underwent combined posterior labral repair for posterior instability or multidirectional instability, and shoulders with isolated capsular repair or humeral avulsion of glenohumeral ligament repair.

All operations were performed with the patient under general anesthesia in the lateral decubitus position. ABR was performed using the single-row suture anchor fixation technique with at least 5 suture anchors. For the treatment of bony Bankart lesions, ABBR was performed without resection of the fragment for all patients with a bony Bankart lesion.¹⁹ The anterior inferior glenohumeral ligament (AIGHL)–labral complex was detached, together with the bone fragment, and mobilized from the glenoid neck to the 6-o’clock position. To restore capsulolabral tension, we did not aim for anatomic reduction of the bone fragment in shoulders with recurrent instability. However, in shoulders with a large bone fragment, we performed anatomic reduction, if possible, to avoid incongruity between the glenoid defect and bone fragment. Until 2013, no bone grafting was performed, even in shoulders with a large glenoid defect, but after 2014, B&B has been performed when a small fragment or no bone fragment is present in shoulders with a large glenoid defect. Furthermore, B&B has also been performed even in cases of a large bone fragment in patients who requested bone grafting. As stated, these shoulders were excluded from the current study. Remplissage or bone grafting was not performed, even in shoulders with a large Hill-Sachs lesion.

Patients wore a brace for 4 weeks postoperatively. They started passive range of motion exercises after 2 weeks, but flexion and external rotation with the arm at the side were restricted to 150° and 30°, respectively, until 4 weeks after surgery. For collision/contact athletes, contact training was not permitted for at least 6 months after surgery, and competitive sports participation was not permitted for at least 8 months.

Glenoid rim morphologic characteristics were evaluated preoperatively in all patients, and CT was usually performed at the first hospital visit. If the surgical procedure was performed a long time (longer than 6 months) after the first CT scan, patients were evaluated using CT again just before the operation. CT scanning and image reconstruction were performed using a whole-body scanner (spiral scan, 0.5-mm slice thickness, 0.3-mm reconstruction, and 3D edit mode) (Aquilion scanner; Canon Medical Systems Corporation). For multiplanar reconstruction, CT data were analyzed using the Digital Imaging and Communications in Medicine picture archiving and communication system (Mitsubishi Heavy Industries Mechatronics Systems).

To quantify the glenoid defect, the inferior portion of the glenoid rim was approximated to a true circle on en face 3D-CT scans that were reconstructed without the head of the humerus.^17-20 The extent of the glenoid defect was calculated as a percentage of the glenoid width (Figure 1). The width of the bone fragment (C) was measured on the image that gave the clearest view of the articular surface of the fragment,^17-19 and the size of the bone fragment was defined relative to the glenoid rim. To determine the intra- and interobserver reliabilities, we compared 2 intraobserver measurements performed 1 month apart (S.N.) and measurements by 2 independent observers (S.N., T.H.), respectively.

To determine whether a Hill-Sachs lesion was on-track or off-track, we used the method by Di Giacomo et al.⁵

The participants were divided into 2 groups according to the glenoid defect size (13.5%-<20%, medium defect; ≥20%, large defect). Then, the bone fragment size in each defect group was investigated and classified into 4 groups (no, 0%; small, >0%-<5%; medium, 5%-<10%; large, ≥10%). The correlation between glenoid defect size and bone fragment size was also investigated.

To clarify the factors influencing the bone fragment size, their relationship with the period since primary instability and the total number of dislocation and subluxation events was investigated.

The postoperative recurrence rate in each combination of glenoid defect size and bone fragment size was investigated for competitive athletes aged <30 years who underwent ABR and were followed for a minimum of 2 years. At final follow-up, all patients came to our hospital. Postoperative recurrence was defined as a report of dislocation or subluxation, which was confirmed via physical examination, imaging studies (magnetic resonance imaging or CT), or both.

Statistical analysis was performed using JMP software (Version 14.0.0; SAS Institute Inc). Comparison of mean values between 2 groups was performed using Student t test or Mann-Whitney U test. Comparison of mean values among 3 groups was done using 1-factor analysis of variance or the Kruskal-Wallis test, and a post hoc Tukey test was performed after analysis of variance. Comparisons of the postoperative recurrence rate were conducted using the Fisher exact probability test. The correlation between 2 groups was analyzed using Spearman rank correlation.

When P values for the comparison of mean values and postoperative recurrence rate were <.05, a post hoc power analysis was performed. If the study had sufficient statistical power (1 –β≥ 0.8), we determined it to be a significant difference.

To investigate the intra- and interobserver reliabilities of the measurements of glenoid defect and bone fragment size, we determined the intraclass correlation coefficient (1,1) and interclass correlation coefficient (2,1); a value ≥0.8 was considered good.

Results

Patient Characteristics

At our hospital, between July 2011 and March 2018, primary stabilization surgery for recurrent anterior instability was performed in 290 consecutive shoulders excluding shoulders that underwent revision surgery. There were 47 shoulders without a glenoid defect, 127 shoulders with a small glenoid defect (<13.5%), and 116 shoulders with a larger glenoid defect (≥13.5%). Among shoulders with a larger glenoid defect, 20 shoulders that underwent B&B were excluded from the present study; thus, 96 shoulders that underwent ABR using JuggerKnot soft anchors (Zimmer Biomet) without any combined reinforcement procedure were the focus of the present study.

The majority of our participants were competitive athletes aged <30 years (64 male and 7 female) (Table 1). The participants were further divided into 2 groups stratified by the glenoid defect size: 60 shoulders with a glenoid defect of 13.5% to <20% (medium defect group) and 36 shoulders with a glenoid defect of ≥20% (large defect group). The mean age at operation for these groups was 23.8 ± 10.1 years and 22.2 ± 7.3 years, respectively, and the mean age at primary instability was 19.1 ± 7.4 years and 17.6 ± 3.8 years, respectively; thus, there was no statistical difference between the 2 defect groups (P = .424 and P = .286, respectively). The mean period since primary instability was 4.6 ± 7.1 years and 4.3 ± 6.7 years for the medium and large defect groups, respectively, which was not statistically different (P = .866). In contrast, the mean number of instability events for the 2 groups was 16.1 ± 23.4 and 38.5 ± 75.9, respectively, such that instability events were more frequent in the large defect group (P = .037).

Table 1

Patient Characteristics^a

	Glenoid Defect Size
	Medium (13.5%-<20%)	Large (≥20%)	Total
Patients	60	36	96
Type of sports (competitive athletes aged <30 y)
Rugby	11	14	25
American football	9	7	16
Contact sports	18 (female, 6)	3	21
Overhead sports	5	4 (female, 1)	9
Sex
Male	51	34	85
Female	9	2	11
Age at operation
10-19 y	31	17	48
20-29 y	16	14	30
30-39 y	7	3	10
40-49 y	4	2	6
50-59 y	2	0	2
Age at primary instability
10-19 y	44	30	74
20-29 y	13	5	18
30-59 y	3	1	4
Period since primary instability
<1 y	22	6	28
1 y	10	8	18
2-5 y	14	17	31
≥6 y	14	5	19
Total instability events
2-5 events	23	4	27
6-10 events	15	9	24
11-20 events	13	11	24
≥21 events	9	12	21
Glenoid track
On-track lesion	49	19	68
Off-track lesion	11	17	28

Values are expressed as No. of patients. Contact sports: soccer, 7; martial arts, 4; judo, 3; handball, 3; others, 4. Overhead sports: baseball, 6; volleyball, 3.

Correlation Between Glenoid Defect Size and Bone Fragment Size

The mean glenoid defect size was 16.2% ± 2.1% in the medium defect group and 23.8% ± 3.2% in the large defect group. The mean bone fragment size was 6.7% ± 5.1% in the medium defect group and 8.9% ± 4.9% in the large defect group (P = .042). The intraobserver reliabilities for the measurement of glenoid defect size and bone fragment size were 0.985 and 0.953, respectively, and the interobserver reliabilities were 0.914 and 0.845, respectively.

The bone fragment size in each glenoid defect group is shown in Table 2. A medium or large bone fragment was more common in the large defect group (P = .252).

Table 2

Bone Fragment Size in Each Glenoid Defect Group^a

	Glenoid Defect Size
Bone Fragment Size	Medium (n = 60)	Large (n = 36)	Total (N = 96)
0%	15 (25)	2 (5.6)	17 (17.7)
>0%-<5%	6 (10)	6 (16.7)	12 (12.5)
5%-<10%	23 (38.3)	14 (38.9)	37 (38.5)
≥10%	16 (26.7)	14 (38.9)	30 (31.3)

Values are expressed as n (%) of shoulders.

The correlation coefficient between glenoid defect size and bone fragment size was 0.253 (P = .013) (Figure 2).

Influence of the Period Since Primary Instability and Total Instability Events on Bone Fragment Size

The mean bone fragment size was 8.6% ± 0.5% in 28 shoulders with <1 year since primary instability, 8.0% ± 0.3% in 18 shoulders with 1 year since primary instability, and 6.7% ± 5.1% in 50 shoulders with ≥2 years since primary instability, and thus the time period since primary instability did not influence the bone fragment size (P = .194). Regarding the total number of instability events, the mean bone fragment size was 7.2% ± 0.5% in 28 shoulders with 2 to 5 instability events, 6.6% ± 0.5% in 23 shoulders with 6 to 10 events, and 8.1% ± 5.3% in 45 shoulders with ≥11 events such that total instability events did not influence the bone fragment size (P = .498).

The correlation coefficient was −0.253 between bone fragment size and the time period since primary instability (P = .013) and 0.050 between bone fragment size and total instability events (P = .630).

Influence of Glenoid Defect Size and Bone Fragment Size on Postoperative Recurrence After ABR for Younger Competitive Athletes

Among 71 competitive athletes aged <30 years, 64 athletes could be followed for a minimum of 2 years (follow-up rate, 90.1%), and postoperative recurrence was recognized in 7 of 64 shoulders (10.9%) (Table 3). The mean follow-up period in shoulders without postoperative recurrence was 28.6 ± 10.4 months (range, 24-67 months), and the mean period from surgery to recurrence was 14.9 ± 14.1 months (range, 6-45 months). Whereas postoperative recurrence was recognized in 7 of 38 (18.4%) athletes in the medium defect group, it was not recognized in 26 athletes in the large defect group (P = .036). In contrast, postoperative recurrence was recognized in 4 of 12 (33.3%) athletes with a small fragment or no fragment and in 3 of 52 (5.8%) athletes with a medium or large fragment (P = .019). Among 16 athletes with an off-track lesion, postoperative recurrence was recognized in only 1 athlete.

Table 3

Postoperative Recurrence Rate in Each Combination of Glenoid Defect Size and Bone Fragment Size^a

	Glenoid Defect Size
Bone Fragment Size	Medium	Large	Total
0%	1/6 (16.7)		1/6 (16.7)
>0%-<5%	3/4 (75)Off: 1/1	0/2 (0)Off: 0/2	3/6 (50)Off: 1/3
5%-<10%	1/18 (5.6)Off: 0/2	0/12 (0)Off: 0/5	1/30 (3.3)Off: 0/7
≥10%	2/10 (20)Off: 0/1	0/12 (0)Off: 0/5	2/22 (9.1)Off: 0/6
Total	7/38 (18.4)Off: 1/4	0/26 (0)Off: 0/12	7/64 (10.9)Off: 1/16

Values are expressed as No. of recurrence/total shoulders (recurrence rate, %). “Off” refers to the recurrence rate in shoulders with an off-track lesion.

Discussion

The most important finding of the present study was that a larger bone fragment frequently remained in shoulders with a subcritical glenoid defect and was associated with lower recurrence rate after ABR for younger competitive athletes.

We sometimes encounter patients with chronic instability in whom the bone fragment is small compared with the size of the glenoid defect. Among the reports regarding small bone fragments, Nakagawa et al¹⁸ investigated the correlation between the time period since primary injury and the bone fragment absorption in patients with bony Bankart lesions. Those investigators reported that the bone fragment displayed a marked decrease in size relative to the glenoid defect within 1 year of the primary event. In contrast, several authors have reported that the glenoid defect can be enlarged by damage due to recurrent dislocation and subluxation,^7,15,20 so it is possible that the bone fragment appears too small because the glenoid defect itself has become larger. In any event, there is no doubt that the mismatch between glenoid defect and bone fragment becomes greater with more dislocations and subluxations and a longer period after primary trauma.

In the present study, to easily investigate the relationship between the glenoid defect size and bone fragment size, we restricted the patients to those with shoulders having a subcritical or larger glenoid defect because a bone fragment was hypothesized to be large when a glenoid fracture occurred. Consequently, it was clarified that a larger bone fragment frequently remained in shoulders with a large glenoid defect (≥20%) at recurrent instability but a bone fragment frequently diminished or disappeared in shoulders with a medium glenoid defect (13.5%-<20%). Although the correlation coefficient between glenoid defect size and bone fragment size was 0.253, a bone fragment became larger as a glenoid defect became larger. Regarding the period since primary instability and the total number of dislocation and subluxation events, their influence on the bone fragment size was compatible with previous reports even in shoulders with a subcritical glenoid defect.^7,15,18,20

A glenoid defect of 13.5% has recently been recognized as a subcritical glenoid defect,^{4,8,12,13,21,26,27} for which ABR is often considered a contraindication for collision/contact athletes or military personnel. In the present study, the postoperative recurrence rate after ABR for younger competitive athletes was low in shoulders with such a subcritical glenoid defect. To our surprise, among shoulders with a glenoid defect of ≥20%, which was regarded as a critical glenoid defect, no postoperative recurrence was recognized. As a large bone fragment frequently remained in shoulders with a large glenoid defect (≥20%), such favorable results might be achieved. Recently, Etoh et al⁶ reported that the fragment-type glenoid defect (avulsion fracture) was observed at the time of dislocation experimentally in a dislocation model. Most of the large bone fragments in the large defect group might have been created by a single dislocation as an avulsion fracture, and their size might have been maintained even after several instability events. Accordingly, even if a subcritical glenoid defect is observed, ABR should not be automatically abandoned because a larger bone fragment frequently remained in shoulders with a subcritical glenoid defect.

A limitation of the present study was the retrospective design, although the preoperative CT data were collected prospectively. The indication for stabilization surgery changed in 2014, and B&B has been performed when a small or no bone fragment is present in shoulders with a large glenoid defect; thus, selection bias might have been present for the analysis of the prevalence and size of bone fragments. The small number of patients in some groups made statistical analysis difficult. This study investigated a single surgical procedure performed by a single surgeon, and the postoperative follow-up period was quite short.

Conclusion

Footnotes

Submitted March 25, 2021; accepted August 13, 2021.

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

ORCID iD

Takehito Hirose

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