| Background and objectivesThe shoulder joint is the most flexible joint in the human body,which belongs to the typical multi axis ball joint,humeral head spherical,small and shallow glenoid,surrounded by fibrous cartilage of the labrum deepened the articular fossa depth,but still can only accommodate the humeral head 1/4-1/3.The structure of the shoulder joint determines the magnitude of the joint movement,but also reduces the stability of the joint.The shoulder joint capsule is thin and loose,and the lower wall is relatively weak,the humeral head is often slipped from the lower part when the shoulder joint dislocation occurs,and the anterior inferior dislocation occurs.The shoulder joint dislocation brings great pain and inconvenience to the patient’s life and work.There is a serious shoulder dislocation accompanied by bone Bankart damage.The incidence of Bankart damage in patients with recurrent shoulder dislocation was 41%.This kind injury can seriously affect the stability of the shoulder,so active surgical treatment is necessary.Bankart bone injury due to shoulder labrum anterior fracture or with recurrent anterior dislocation of the shoulder of the labrum defect common in traumatic anterior dislocation of the shoulder or anterior dislocation,high incidence,accounting for glenohumeral instability in traumatic 5.4%-70%.Bony Bankart lesion refers to the inferior glenohumeral ligament labral complex injury accompanied by lower glenoid before avulsion fracture.Because of the bone defect in the anterior part of the glenoid cavity,the pear shaped glenoid cavity can be changed into an inverted pear shaped structure.Bankart lesion,initially reported in 1938 on a series of 27 patients with anterior shoulder instability by Bankart,is cause by the detachment of the anterior inferior labrum from the glenoid rim and in general affects people who are younger than 35 years of age.Traditional open Bankart repair(OBR)was previously considered as the accepted standard treatment for shoulder stabilization by many surgeons.OBR has been shownto improve glenohumeral jointstability,with recurrence rates below 10% and low failure rates varying between 0 and11%.However,restriction of external rotation and secondary osteoarthritis are the weakness of the open surgery.Although several previous studies have summarized the published studies about OBR versus ABR,most of them are systematic reviews.Some authors concluded open repair has a decreased rate of recurrence;however,the others considered there are no significant differences in failure rates between OBR and ABR.Moreover,several new high-quality studies have been recently published.Therefore,we performed this meta-analysis to determine which procedure has better clinical outcomes in the treatment of Bankart lesion.Methods Search strategyThe search was performed in the online databases PubMed(1966 to December 2016)and EMBASE(1966 to December 2016).Only studies published in English were included.The reference lists were also checked for possible eligible article.Thekeywords used for retrieval were: anterior shoulder instability,Bankart lesion,dislocation,and subluxation.Inclusion and exclusion criteria.Inclusion criteria were set as follows: 1)English literature,2)comparison of open versus arthroscopic shoulder stabilization for Bankart lesion,3)all included patients aged 18 years or older,4)a minimum of 2-year follow-up,and 5)available data for recurrence,and shoulder functional scores.Exclusion criteria were: 1)non-English language literature;2)studies with less than 2-year follow-up;3)original data being insufficient for a meta-analysis;4)vitro studies or non-comparable studies;5)included patients with younger than 18 years;and 6)sample size being less than 50.To avoid repetition,if multiple articles included the same patient population,then the results were pooled.Data extraction and evaluation of methodological qualityData were extracted and evaluated independently by two researchers and then verified by the third senior researcher.The extracted information included: 1)the characteristics of the included studies,including the authors,the type of study design,and publication date;2)the demographics of included subjects,including sample size,age,gender,duration of follow-up,from injury to surgery time,and the surgical details;and 3)details of outcomes.Disagreement between the authors was resolved by discussion.In cases of missing necessary data,corresponding authors the eligible trials were contacted to obtain this data.The methodological quality of each randomized controlled trial(RCT)was assessed using the Physiotherapy Evidence Database(PEDro)scale.The Newcastle-Ottawa(NO)quality assessment tool was used to assess the quality of each non-randomized study.The NO scales based on standard quality ratings were as follows: 1)selection of study groups;2)comparability of study groups;and 3)ascertainment of the outcome of interest(cohort study).Outcome measurementThe stability and range of motion(ROM)of shoulder were postoperatively applied as the primary outcome in patients with open versus arthroscopic repair for Bankart lesion.Shoulder was considered stable if recurrent dislocations and subluxations were not observed,or apprehension test was negative.The ROM mainly included loss of external rotation with the arm in 90° of abduction.Secondary outcomes under investigation included functional outcomes evaluated using the Rowe grading system,Constant score,ASES Scale,UCLA shoulder rating scale,and surgical time.ResultAfter full-text reviews,a total of 11 independent studies were included in this meta-analysis,with a cumulative sample size of 1022 at final follow-up(Table1).Four of all included studies was RCTs and the rest were cohort study.The pooled characteristics of the included studies are shown in Table 1.The methodological quality of RCTs is provided in Table 2.Table 3 represents the quality of the four cohort studies,as determined using the NO scale.As shown in Figure 2,publication bias was evaluated using funnel plot,which was acceptably symmetrical.Primary outcomesAll 11 studies assessed stability of the shoulder postoperatively(Figure 3A),including 512 patients in arthroscopic group and 510 patients in open group.After meta-analysis using a fixed-effects model(I 2 =34%),a statistically significant difference was observed between the two treatment groups in respect to shoulder stability(P=0.008,RR=0.94,95% CI: 0.89 to 0.98).Data on ROM were provided in four studies(Figure 3B).As one of the study’s primary outcome,the result of analysis revealed a better ROM in patients managed with arthroscopic repair,compared to those who received OBR(P<0.001,SMD=–0.47,95% CI: –0.72 to –0.22),without significant heterogeneity.Secondary outcomesAfter meta-analysis on postoperatively functional outcomes,no significant differences were shown between the two treatment strategies,in terms of Rowe(P=0.16),ASES(P=0.24),Constant(P=0.32),and ULCA score(P=0.18)(Figure 4A–4D).Intraoperative surgical times were only obtained in two trials,which included 115 patients in ABR group and 108 patients in OBR group.There was no significant difference between the two groups(P=0.08,SMD=-2.01,95% CI:–4.29 to 0.27),with a highly significant heterogeneity(I2=97%)(Figure 4E).However,there was a trend towards decreased surgical times in the arthroscopic group,compared to those who received open treatment procedure.Conclusion1.Arthroscopic repair of Bankart damage has the advantages of smaller incision,shorter operation time,less postoperative pain,lower complication rate,and higher recurrence rate.2.Open repair of Bankart damage can result in a more stable shoulder joint after surgery,but a reduction in shoulder mobility.The patients with Bankart injury should be clearly classified,the choice of surgical methods need a larger sample size and more scientific and reasonable further test. |
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