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Anterior glenoid rim erosion in the early stage after arthroscopic Bankart repair affects postoperative recurrence

Open AccessPublished:November 02, 2022DOI:https://doi.org/10.1016/j.jseint.2022.10.005

      ABSTRACT

      Background

      Recent studies reported that anterior glenoid rim erosion can occur in the early period after arthroscopic Bankart repair (ABR) for traumatic anterior shoulder instability. However, it is unknown whether such erosion is a risk factor for postoperative recurrence. This study evaluated risk factors for postoperative recurrence after ABR, specifically aiming to elucidate whether reduction of postoperative glenoid width due to anterior glenoid rim erosion is one of such factors.

      Method

      A total of 220 shoulders that underwent ABR alone between 2013 and 2020 were retrospectively investigated. Patient age at surgery, whether the patient was a collision/contact athlete, anchor placement, preoperative glenoid bone defect (%), localization of the Hill-Sachs lesion, and change of glenoid width (%) in the 6 months after surgery were investigated for their statistical relation to recurrence by univariate and multiple logistic regression analysis.

      Results

      Postoperative recurrence occurred in 32 of 220 shoulders (14.5%). In univariate analysis, being a collision/contact athlete was the only variable with a significant effect on recurrence (odds ratio [OR], 2.555; 95% CI, 1.123-5.814; p = .03). Change of glenoid width reduction was larger in those with recurrence than without recurrence, but the difference was not statistically significant (-7.0±6.6% vs -5.0±9.3%; p = .14). However, in multivariate logistic analysis, preoperative glenoid bone defect (%) (adjusted unit OR, 1.076; 95% CI; 1.018-1.137; p = .010) and postoperative change of glenoid width (%) (adjusted unit OR, 0.946; 95% CI, 0.900-0.994; p = .028) had a significant influence on postoperative recurrence.

      Conclusion

      Glenoid width reduction due to anterior glenoid rim erosion after ABR is a risk factor for recurrence.

      Keywords

      Various factors have been reported to be associated with recurrence after arthroscopic Bankart repair (ABR) for traumatic anterior shoulder instability, including younger age
      • Nakagawa S.
      • Mae T.
      • Sato S.
      • Okimura S.
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      Risk Factors for the Postoperative Recurrence of Instability After Arthroscopic Bankart Repair in Athletes.
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      Age, participation in competitive sports, bony lesions, ALPSA lesions, > 1 preoperative dislocations, surgical delay and ISIS score > 3 are risk factors for recurrence following arthroscopic Bankart repair: a systematic review and meta-analysis of 4584 shoulders.
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      Predicting Failure After Primary Arthroscopic Bankart Repair: Analysis of a Statistical Model Using Anatomic Risk Factors.
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      • Burkhart S.S.
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      Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.
      ,
      • Hayashida K.
      • Yoneda M.
      • Nakagawa S.
      • Okamura K.
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      Arthroscopic Bankart suture repair for traumatic anterior shoulder instability: analysis of the causes of a recurrence.
      ,
      • Loppini M.
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      • et al.
      Is the Instability Severity Index Score a Valid Tool for Predicting Failure After Primary Arthroscopic Stabilization for Anterior Glenohumeral Instability?.
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      • Okimura S.
      • Kuroda M.
      Risk Factors for the Postoperative Recurrence of Instability After Arthroscopic Bankart Repair in Athletes.
      , preoperative glenoid defect size
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      • Neyton L.
      Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair.
      • Burkhart S.S.
      • De Beer J.F.
      Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.
      ,
      • Nakagawa S.
      • Mae T.
      • Sato S.
      • Okimura S.
      • Kuroda M.
      Risk Factors for the Postoperative Recurrence of Instability After Arthroscopic Bankart Repair in Athletes.
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      • et al.
      Effect of an anterior glenoid defect on anterior shoulder stability: a cadaveric study.
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      • Spencer H.T.
      Predicting Failure After Primary Arthroscopic Bankart Repair: Analysis of a Statistical Model Using Anatomic Risk Factors.
      and localization of bone defect of the humeral head (i,e; Hill-Sachs lesion (HSL))
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      • Obopilwe E.
      • Cote M.P.
      • et al.
      The effect of a combined glenoid and Hill-Sachs defect on glenohumeral stability: a biomechanical cadaveric study using 3-dimensional modeling of 142 patients.
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      • Locher J.
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      • Buchmann S.
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      • Denaro V.
      • et al.
      Hill-Sachs Off-track Lesions as Risk Factor for Recurrence of Instability After Arthroscopic Bankart Repair.
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      • Yamamoto N.
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      • Seki N.
      • Shimada Y.
      • et al.
      Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track.
      ,
      • Yian E.H.
      • Weathers M.
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      • Sodl J.F.
      • Spencer H.T.
      Predicting Failure After Primary Arthroscopic Bankart Repair: Analysis of a Statistical Model Using Anatomic Risk Factors.
      . Of these factors, preoperative glenoid bone defect size may be the most relevant, with biomechanical studies demonstrated that a defect of over 20% significantly decreases anterior stability.
      • Itoi E.
      • Lee S.B.
      • Berglund L.J.
      • Berge L.L.
      • An K.N.
      The effect of a glenoid defect on anteroinferior stability of the shoulder after Bankart repair: a cadaveric study.
      ,
      • Yamamoto N.
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      • Abe H.
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      • Seki N.
      • Minagawa H.
      • et al.
      Effect of an anterior glenoid defect on anterior shoulder stability: a cadaveric study.
      ,
      • Yamamoto N.
      • Muraki T.
      • Sperling J.W.
      • Steinmann S.P.
      • Cofield R.H.
      • Itoi E.
      • et al.
      Stabilizing mechanism in bone-grafting of a large glenoid defect.
      Accordingly, depending on the extent of anterior glenoid bone loss, surgeons may need to change the surgical procedure from ABR alone to performing coracoid transfer or some augmentation techniques.
      • Di Giacomo G.
      • Piscitelli L.
      • Pugliese M.
      The role of bone in glenohumeral stability.
      ,
      • Itoi E.
      • Yamamoto N.
      • Kurokawa D.
      • Sano H.
      Bone loss in anterior instability.
      Thus, quantitative preoperative morphological evaluation of bone loss in the affected shoulders by imaging modalities such as computed tomography (CT) or magnetic resonance imaging is an essential step in the current treatment strategy for traumatic anterior shoulder instability.
      • Lubowitz J.H.
      • Brand J.C.
      • Rossi M.J.
      Proper Evaluation of Bone Loss Determines Shoulder Instability Indications and Outcomes.
      ,
      • Nakagawa S.
      • Hanai H.
      • Mae T.
      • Hayashida K.
      • Yoneda M.
      Bipolar Bone Loss in Male Athletes With Traumatic Anterior Shoulder Instability: An Evaluation Using a New Scoring System.
      ,
      • Shaha J.S.
      • Cook J.B.
      • Rowles D.J.
      • Bottoni C.R.
      • Shaha S.H.
      • Tokish J.M.
      Clinical Validation of the Glenoid Track Concept in Anterior Glenohumeral Instability.
      However, recent studies have raised new concerns that may affect the outcome after ABR.
      • Hirose T.
      • Nakagawa S.
      • Iuchi R.
      • Mae T.
      • Hayashida K.
      Progression of Erosive Changes of Glenoid Rim After Arthroscopic Bankart Repair.
      ,
      • Hirose T.
      • Nakagawa S.
      • Uchida R.
      • Yokoi H.
      • Ohori T.
      • Tanaka M.
      • et al.
      On-the-Edge Anchor Placement May Be Protective Against Glenoid Rim Erosion After Arthroscopic Bankart Repair Compared to on-the-Face Anchor Placement.
      The earlier study indicated that glenoid bone loss can occur not only preoperatively but also postoperatively. In other words, the authors revealed that anterior glenoid rim erosion can progress within 6 months after ABR. Postoperative glenoid rim erosion has been shown to occur in up to 54% of patients without a preoperative bony Bankart lesion. On the other hand, another study conversely advocated no erosive change after ABR, suggesting still controversial over this morphological change.
      • Nagaya L.H.
      • Yamamoto N.
      • Shinagawa K.
      • Hatta T.
      • Itoi E.
      Does glenoid remodeling occur with an erosion-type bone loss after arthroscopic Bankart repair?.
      If this negative morphological change actually does occur, there is some concern whether it affects postoperative recurrence.
      • Hirose T.
      • Nakagawa S.
      • Iuchi R.
      • Mae T.
      • Hayashida K.
      Progression of Erosive Changes of Glenoid Rim After Arthroscopic Bankart Repair.
      However, to date, no studies have specifically evaluated whether postoperative bone loss may be a risk factor for recurrence after ABR. Therefore, the purpose of this study was to elucidate the risk factors for recurrence after ABR alone, including anterior glenoid rim erosion in the early period after surgery. Our hypothesis was that glenoid rim erosion after ABR has a significant negative influence on postoperative recurrence.

      Methods

      The study population consisted of consecutive patients who underwent ABR for traumatic anterior shoulder instability between January 2013 and July 2020 and had a minimum follow-up of 2 years. The study exclusion criteria were as follows: ABR combined with the open Bristow procedure (mainly for collision/contact athletes with a large glenoid defect); combined posterior labrum repair for posterior instability or multi-directional instability; isolated capsular repair or humeral avulsion of the glenohumeral ligament repair; ABR performed with anchors other than JuggerKnot® (Zimmer-Biomet Corporation, Warsaw, IN, USA); and revision surgery for recurrence. Patients who missed either the pre- and postoperative CT scan of the glenoid and humeral head or who underwent the first postoperative CT more than 6 months after surgery were also excluded. The study was approved by our institutional review board and ethics committee, and written informed consent was obtained from all participants before treatment.

      Surgical procedure and postoperative rehabilitation

      The same orthopedic surgeon performed all surgical procedures in this series. Labral repair was finished by the single-row suture anchor technique with at least five 1.4-mm JuggerKnot® anchors (single loaded) in simple suture manner. Sutures were passed through the capsule-labral complex and tied with sufficient tension so that the complex was reattached at least 1 hour above its detached position. In patients with a relatively large bony Bankart lesion, the bone fragment was reduced by passing sutures through it, but in patients with a small bone fragment, the fragment was carefully preserved and sutured together with the capsule-labral complex. In this study series, 2 different anchor placements were applied at the time of suture anchor insertion; on-the-face anchoring was used until the end of March 2018, and on-the-edge anchoring thereafter. In patients with on-the-face anchoring, articular cartilage around the anterior glenoid rim was carefully removed with a radiofrequency device, and a 3- to 4-mm wide trough was created. Then, anchors were inserted into the glenoid just posterior to the trough. This technique was used to encourage bleeding from the subchondral bone and allow the repaired soft tissue to heal sufficiently to the bone.

      Burkhart SS, Lo IKY, Brady PC. Burkhart's view of the shoulder : a cowboy's guide to advanced shoulder arthroscopy. Philadelphia: Lippincott Williams & Wilkins; 2006. (ISBN No. 0781780004 (alk. paper) 9780781780001)

      In addition, this approach also has the advantage that it increases the height of the repaired labrum.
      • Park J.Y.
      • Lee J.H.
      • Chung S.W.
      • Oh K.S.
      • Noh Y.M.
      • Kim S.J.
      Does Anchor Placement on the Glenoid Affect Functional Outcome After Arthroscopic Bankart Repair?.
      On the other hand, in patients with on-the-edge anchoring, anchors were inserted as anteriorly as possible on the glenoid edge, and the minimum amount of anterior cartilage was removed to expose the bone edge of the anchor insertion site. This technique was adopted because of findings that it may protect against postoperative erosive change of the glenoid rim by reducing stress shielding around the rim.
      • Inoue K.
      • Suenaga N.
      • Oizumi N.
      • Yamaguchi H.
      • Miyoshi N.
      • Taniguchi N.
      • et al.
      Glenoid bone resorption after Bankart repair: finite element analysis of postoperative stress distribution of the glenoid.
      We did not use the Remplissage technique in any patients. After surgery, shoulders were immobilized in the internal rotation position with a brace. Motion exercises were permitted from 2 weeks postoperatively, and patients removed the brace 4 weeks after surgery. A return to full athletic activity 6 months after surgery was permitted in all athletes except collision/contact athletes, who were allowed to return to full competitive activity after 8 months.

      CT scan

      All patients underwent a preoperative CT; the first postoperative CT was performed between 4-6 months. CT was performed with an Aquilion™ scanner (Canon Medical Systems Corporation, Tochigi, Japan) at a slice thickness of 0.50 mm, and the obtained DICOM data of bilateral shoulders of each patient were then reconstructed into 3-dimensional (3D) bone models to evaluate the en face view of the glenoid and posterior side of the humeral head.

      Imaging analysis

      Preoperative glenoid bone defect

      The percentage of preoperative glenoid bone defect was measured in the preoperative en face glenoid 3D bone model by using the assumed circle method described in the report by Nakagawa et al.
      • Nakagawa S.
      • Hirose T.
      • Uchida R.
      • Yokoi H.
      • Ohori T.
      • Sahara W.
      • et al.
      A Glenoid Defect of 13.5% or Larger Is Not Always Critical in Male Competitive Rugby and American Football Players Undergoing Arthroscopic Bony Bankart Repair: Contribution of Resultant Large Bone Fragment.

      Glenoid Track and HSL

      Localization of the HSL was also measured in the preoperative 3D bone model of the humeral head on the affected side.
      • Funakoshi T.
      • Hartzler R.U.
      • Stewien E.
      • Burkhart S.S.
      Hill-Sachs Lesion Classification by the Glenoid Track Paradigm in Shoulder Instability: Poor Agreement Between 3-Dimensional Computed Tomographic and Arthroscopic Methods.
      In cases with unilateral involvement, the distance between the medial margin of the HSL and rotator cuff attachment was compared with the distance of the glenoid track determined from the unaffected glenoid width; in cases with bilateral involvement, the assumed diameter of the affected glenoid was used as the reference. Then, in each case, the HSL was classified as an on-track HSL other than a peripheral-track one, peripheral-track HSL, or off-track HSL.
      • Di Giacomo G.
      • Itoi E.
      • Burkhart S.S.
      Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from "engaging/non-engaging" lesion to "on-track/off-track" lesion.
      ,
      • Yamamoto N.
      • Shinagawa K.
      • Hatta T.
      • Itoi E.
      Peripheral-Track and Central-Track Hill-Sachs Lesions: A New Concept of Assessing an On-Track Lesion.

      Change of glenoid width

      The percentage change in glenoid width as a result of anterior glenoid rim erosion was assessed in accordance with the report by Hirose et al.
      • Hirose T.
      • Nakagawa S.
      • Uchida R.
      • Yokoi H.
      • Ohori T.
      • Tanaka M.
      • et al.
      On-the-Edge Anchor Placement May Be Protective Against Glenoid Rim Erosion After Arthroscopic Bankart Repair Compared to on-the-Face Anchor Placement.
      The percent change in the maximum glenoid width diameter perpendicular to the long axis of the glenoid was calculated. The authors reported that this is a reliable method for measuring glenoid width and has a low inter-examiner error. The percentage change of glenoid width (Δ) was calculated relative to the preoperative glenoid width, with increases shown as positive values and decreases shown as negative values. At the time of assessment of shoulders with a bony Bankart lesion, the additional glenoid surface obtained by the postoperative union of the bone fragment was included in the glenoid width if the additional surface was within 3.0 mm of the original one.

      Statistical analysis

      Statistical analysis was performed with JMP software (Version 16.0.0; SAS Institute Inc., Cary, NC, USA). Postoperative recurrence was defined as any report of dislocation or subluxation, and subluxation was defined as an episode of shoulder instability that did not require manual reduction by a health care provider.
      • Nakagawa S.
      • Sahara W.
      • Kinugasa K.
      • Uchida R.
      • Mae T.
      Bipolar Bone Defects in Shoulders With Primary Instability: Dislocation Versus Subluxation.
      For 2-group comparison by univariate analysis, the Wilcoxon test and Chi-square test were used. Then, multivariate logistic regression analysis of the following variables was performed to determine the risk factors for recurrence: (1) age at surgery, (2) type of athlete (collision/contact athlete or not), (3) anchor placement (on-the-face or on-the-edge anchoring), (4) preoperative glenoid bone defect (%), (5) localization of the HSL (on-track other than peripheral-track HSL or off-/peripheral-track HSL), and (6) change of glenoid width (%) within 6 months after surgery. These variables were selected from those that were found or suspected to be risk factors in previous studies on recurrence after ABR or that were the target of this study. Then, the adjusted OR and statistical significance were calculated. Statistical significance was assumed at a p value of less than 0.05.

      Results

      Among 520 shoulders that underwent ABR for traumatic anterior shoulder instability, 300 shoulders were excluded because of missing optimal CT scan data, use of anchors other than JuggerKnot®️, concomitant coracoid transfer surgery, or lack of a follow-up of at least 2 years. Thus, a total of 220 shoulders met the study criteria. Patient demographics are shown in Table 1. The mean age at surgery was 21.7 years, and about half of the patients were collision/contact athletes. The first postoperative CT evaluation was performed at 4.5 months, and the mean decrease in glenoid width was more than 5%. According to preoperative glenoid structure, change of glenoid width in normal, erosion, and bony Bankart type was -9.6±6.2%, -5.2±6.2%, and -3.1±10.6%, respectively. The rate in normal glenoid type was higher than those in erosion and bony Bankart type (p = .001 and .0004).
      Table 1Patient demographics
      N220
      Age at surgery (y.o) a21.7±10.3 [20.3-23.1]
      Sport category- Collision/contact117
      - Non collision/contact103
      Preop. glenoid structure- Normal58
      - Erosion56
      - bony Bankart106
      Glenoid bone defect (%) b7.7±7.2 [6.7-8.6]
      Hill-Sachs lesion- On-track other than peripheral-track171
      - Peripheral-track43
      - Off-track6
      Postop. 1st CT (mos) c4.5±0.7 [4.4-4.6]
      Change of glenoid width (%) d-5.3±9.0 [-6.5 to -4.1]
      a, b, c, d; Data were reported as means ± standard deviations. []; 95% confidence intervals.

      Univariate analysis

      Postoperative recurrence occurred in 32 of 220 shoulders (14.5%). Table 2 shows each parameter according to the presence or absence of postoperative recurrence. In univariate analyses, the only variable that significantly affected recurrence was being a collision/contact athlete (OR, 2.555; 95% CI, 1.123-5.814; p = .03). Regarding the change of glenoid width, shoulders with recurrence were revealed to have 7.0±6.6% reduction while those without recurrence were 5.0±9.3% reduction, but the difference was not statistically significant. Additionally, among 106 shoulders with bony Bankart type glenoid, 55 shoulders achieved bone fragment healing while 14 were nonunion and 37 showed resorption of bone fragment. Recurrence rate was higher in those without union than with union (7/55 (12.7%) vs 13/51 (25.5%), p = .09). The glenoid width decreased in fragment nonunion (-11.2±5.5%) or resorption (-9.2±6.0%) but increased in fragment union (3.1±10.3%).
      Table 2Parameters depending on postoperative recurrence
      No recurrenceRecurrencep-value
      N18832
      Age at surgery (y.o) a22.3±10.9 [20.7-23.8]18.4±5.0 [16.6-20.2].06
      Sport category- Collision/contact9423.03
      - Non collision/contact949
      Preop. glenoid structure- Normal544.12
      - Erosion488
      - bony Bankart8620
      Anchor placement- On-the-face12422.76
      - On-the-edge6410
      Preop. glenoid bone defect (%) b7.3±6.7 [6.3-8.3]9.8±9.5 [6.4-13.2].20
      Hill-Sachs lesion- On-track other than peripheral-track14427.64
      - Peripheral-track385
      - Off-track60
      Change of glenoid width (%) c-5.0±9.3 [-6.4 to -3.7]-7.0±6.6 [-9.3 to -4.6].14
      a, b, c; Data were reported as means ± standard deviations. []; 95% confidence intervals.

      Multivariate logistic regression analysis

      In multivariate logistic regression analysis, the extent of the preoperative glenoid bone defect and the change of glenoid width on the first postoperative CT were identified as risk factors for recurrence after ABR alone. The OR of recurrence was 1.08 for every 1% increase in the extent of the preoperative glenoid bone defect and 1.06 (1/0.946) for every 1% decrease in the postoperative change of glenoid width. Although being a collision/contact athlete and being younger at surgery tended to be risk factors for postoperative recurrence, the differences were not statistically significant. The localization of the HSL was not associated with postoperative recurrence (Table 3).
      Table 3Multivariate logistic regression analysis for postoperative recurrence
      Adjusted odds ratio
      odds ratio; unit odds ratio for glenoid bone defect (%) and change of glenoid width (%)
      95% CIp-value
      Bold; statistical significance.
      Preop. glenoid bone defect (%)1.0761.018-1.137.010
      Change of glenoid width (%)0.9460.900-0.994.028
      Collision/contact athlete2.1540.898-5.170.086
      Age at surgery (y.o)0.9370.868-1.011.093
      On-the-edge anchor placement1.3320.528-3.363.544
      Off-/peripheral-track HSL0.7150.236-2.168.553
      HSL; Hill-Sachs lesion.
      odds ratio; unit odds ratio for glenoid bone defect (%) and change of glenoid width (%)
      ∗∗ Bold; statistical significance.

      Discussion

      The key finding of this study was that postoperative anterior glenoid rim erosion was found to be a risk factor for recurrence after ABR alone by multivariate analysis. As in previous reports, the extent of the glenoid bone defect before surgery was confirmed to have a critical influence on postoperative recurrence; the second most important factor was reduction of glenoid width due to anterior glenoid rim erosion after surgery.
      Before the present study, postoperative bone resorption could be interpreted as having a limited impact on recurrence because the resorptive change occurs after surgery has achieved adequate soft tissue repair. However, this study showed that postoperative bone resorption has a significant effect on recurrence and therefore must be recognized as a risk factor for postoperative recurrence after ABR. As the previous study showed that patients especially with a preoperative erosive-type glenoid or without union of a bony Bankart lesion show additional postoperative reduction of the glenoid width
      • Hirose T.
      • Nakagawa S.
      • Iuchi R.
      • Mae T.
      • Hayashida K.
      Progression of Erosive Changes of Glenoid Rim After Arthroscopic Bankart Repair.
      , we considered that this 2-step bone defect (i.e., before and after surgery) may represent a strong possibility for postoperative recurrence. We also noted postoperative changes in shoulders with bone fragments, suggesting that the outcome can vary greatly depending on the presence or absence of fragment union. Our data suggested that fragment union results in a larger glenoid, while healing failure of fragment may result in a smaller glenoid and recurrence.
      We found no effect of anchor placement on postoperative recurrence. Hirose et al advocated that on-the-edge anchor placement was more protective against anterior glenoid rim erosion than on-the-face placement, but they also concluded that the postoperative recurrence rates of both methods were almost equivalent.
      • Hirose T.
      • Nakagawa S.
      • Uchida R.
      • Yokoi H.
      • Ohori T.
      • Tanaka M.
      • et al.
      On-the-Edge Anchor Placement May Be Protective Against Glenoid Rim Erosion After Arthroscopic Bankart Repair Compared to on-the-Face Anchor Placement.
      Consistent with this conclusion, in the present study, we found no significant difference between the influence of both placements on postoperative recurrence. This lack of a difference might be because on-the-edge anchoring may compromise the height of the repaired labrum compared with on-the-face anchoring, rather than protecting against glenoid rim erosion. In other words, both techniques have their weakness that may contribute to postoperative recurrence in different ways. However, we believe that on-the-edge anchoring is superior because it preserves bone volume and morphology so that, in case of recurrence, more options are available at the time of revision surgery.
      Similar to previous reports
      • Burkhart S.S.
      • De Beer J.F.
      Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.
      ,
      • Hayashida K.
      • Yoneda M.
      • Nakagawa S.
      • Okamura K.
      • Fukushima S.
      Arthroscopic Bankart suture repair for traumatic anterior shoulder instability: analysis of the causes of a recurrence.
      ,
      • Loppini M.
      • Delle Rose G.
      • Borroni M.
      • Morenghi E.
      • Pitino D.
      • Dominguez Zamora C.
      • et al.
      Is the Instability Severity Index Score a Valid Tool for Predicting Failure After Primary Arthroscopic Stabilization for Anterior Glenohumeral Instability?.
      ,
      • Nakagawa S.
      • Mae T.
      • Sato S.
      • Okimura S.
      • Kuroda M.
      Risk Factors for the Postoperative Recurrence of Instability After Arthroscopic Bankart Repair in Athletes.
      ,
      • Verweij L.P.E.
      • van Spanning S.H.
      • Grillo A.
      • Kerkhoffs G.
      • Priester-Vink S.
      • van Deurzen D.F.P.
      • et al.
      Age, participation in competitive sports, bony lesions, ALPSA lesions, > 1 preoperative dislocations, surgical delay and ISIS score > 3 are risk factors for recurrence following arthroscopic Bankart repair: a systematic review and meta-analysis of 4584 shoulders.
      ,
      • Yian E.H.
      • Weathers M.
      • Knott J.R.
      • Sodl J.F.
      • Spencer H.T.
      Predicting Failure After Primary Arthroscopic Bankart Repair: Analysis of a Statistical Model Using Anatomic Risk Factors.
      , we found that younger age at surgery and being a collision/contact athlete tended to influence recurrence. However, the effects did not reach statistical significance, perhaps because the patient population at our institution is younger and has a much larger proportion of collision/contact athletes. Consequently, we believe that these factors should continue to be considered as possible risks for recurrence after ABR alone.
      In this study, the preoperative localization of HSL had no statistically significant effect on postoperative recurrence. As mentioned above, previous risk analyses did not consider the effect of postoperative glenoid rim erosion. Postoperative glenoid bone may increase in size in cases with healed bony Bankart lesions
      • Kitayama S.
      • Sugaya H.
      • Takahashi N.
      • Matsuki K.
      • Kawai N.
      • Tokai M.
      • et al.
      Clinical Outcome and Glenoid Morphology After Arthroscopic Repair of Chronic Osseous Bankart Lesions: A Five to Eight-Year Follow-up Study.
      ,
      • Nakagawa S.
      • Ozaki R.
      • Take Y.
      • Mae T.
      • Hayashida K.
      Bone fragment union and remodeling after arthroscopic bony bankart repair for traumatic anterior shoulder instability with a glenoid defect: influence on postoperative recurrence of instability.
      but decrease in other cases because of rim erosion. Therefore, a HSL may change from a preoperative on-track lesion to a postoperative off-track lesion or vice versa. Consequently, we considered that the change in the localization of the HSL resulting from a postoperative change in glenoid width is more relevant than the preoperative localization of the HSL.
      The results of this study indicate that surgeons should pay attention to resorptive bone morphological changes after ABR and control activity in patients with a glenoid width reduction. In addition, future research is required to elucidate the causes of this pathology and establish preventive approaches. We believe that such research will lead to more sophisticated surgical interventions for anterior shoulder instability.

      Limitation

      This study has a few limitations. First, because it targeted postoperative recurrence, the effect of postoperative glenoid width reduction on comprehensive shoulder function, including range of motion, pain, and muscle strength, remains unknown. Further investigation is needed to determine whether residual minor instability, although it does not lead to recurrence, is responsible for patients’ postoperative symptoms. Second, postoperative subluxation was defined as an episode of shoulder instability that did not require manual reduction, meaning that it was a subjective, self-reported outcome. Unlike complete dislocation, which requires manual reduction, the occurrence of subluxation may depend on a patient’s perception and therefore may have affected the recurrence rate. Last, the majority of the study population were younger patients and collision/contact athletes. Even though we adjusted for this fact in the multivariate analysis, the uneven distribution compared with the general hospital patient population should be considered when interpreting the results.

      Conclusion

      Glenoid width reduction due to anterior glenoid rim erosion after ABR is a risk factor for recurrence.

      ACKNOWLEDGMENTS

      The authors would like to thank Yamada Translation Bureau, Inc. (https://www.ytrans.com/index.html) for the English language review

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