Shoulder Instability: Bankart Repair, Remplissage and Latarjet

Ligament reconstruction, ACL or PCL, has a 98 to 99% success rate, with failures very rarely seen. Meniscal repair success depends on how much of the meniscus is torn and how early the patient presents, but even large tears repaired a year after injury succeed around 90 to 95% of the time. Shoulder stabilisation surgery, Bankart repair or Latarjet, is 95 to 98% successful when planned correctly, and rotator cuff repair succeeds 90 to 95% of the time.

Blood supply to the meniscus runs from outside to inside, dividing it into three zones. The outer red-red zone near the capsule has decent blood supply, which is why peripheral tears heal well. The middle red-white zone has moderate blood supply and can still be repaired if augmented with orthobiologics. The innermost white-white zone has very poor blood supply, and a peripheral rim tear there is better debrided than repaired with multiple anchors into non-vascular tissue.

The meniscus is the only shock absorber between the femur and the tibia, taking on all the compressive and shear stress of walking, running and sport, and preventing the two bones' cartilage from grinding directly against each other. Once it is removed, that cartilage-on-cartilage contact leads to arthritis within a few years. A patient can function without an ACL, but without a meniscus, arthritis is inevitable.

Not at all, this is a different situation from minimally invasive spine or brain surgery. Arthroscopy actually gives a clearer view of the joint than open surgery would; even opening the knee completely to repair the posterior horn of the meniscus does not give as clear a view as the arthroscope does. In twenty years of practice, an arthroscopy has never needed conversion to an open procedure, provided the surgeon is patient and knows the anatomy well.

All surgery carries some residual risk, similar to how buying a car involves a small residual risk of a road accident that is rarely front of mind. The reassuring fact is that all the major blood vessels and nerves sit outside the knee and shoulder joint capsule, so as long as the anatomy is well understood and the surgery carefully planned, arthroscopy is one of the safest procedures available. Most arthroscopies are done as day-care procedures, with patients going home the same day.

The choice depends on clinical examination, how long ago the injury occurred, the degree of glenoid bone loss, glenoid tracking, and whether the Hill-Sachs lesion is engaging or non-engaging, rather than defaulting to the same procedure for every patient.

Latarjet is used when glenoid bone loss exceeds about 17%, when the lesion is off-track, or after a failed Bankart repair with significant bone loss, since it provides a bony buttress that a soft-tissue Bankart repair cannot.