Abstract
Objectives: Arthroscopic anatomic glenoid reconstruction (AAGR) is a promising treatment approach for shoulder instability, with an exceptional safety profile and low recurrence rates comparable to a Latarjet procedure. Arthroscopic Bankart repair is the traditional repair choice for subcritical glenoid bone loss (GBL), but ongoing debates within the literature deliberate the best procedure to achieve optimal patient outcomes. Using a randomized control trial (RCT) study design, we aimed to compare the functional recovery of AAGR vs Bankart repair for subcritical GBL up to two-years post-operatively. Methods: In this single center, double blinded, prospective RCT, patients aged 16 to 60 with recurrent anterior shoulder instability and subcritical GBL were pre-operatively randomized to AAGR or Bankart repair. Re-dislocation, Western Ontario Shoulder Instability (WOSI) index scores, passive range of motion (ROM) and strength in flexion, abduction, internal rotation, and external rotation were collected pre-operatively, at six-months, one-year, and two-years post-operatively. Demographics were summarized descriptively and compared between groups. Re-dislocation was compared between groups at each post-operative time-point using a Fisher's exact test. A two-way repeated measures analysis of variance (ANOVA) was performed to examine the main effects of group and time, and their interaction, on WOSI scores. The WOSI minimal clinically important difference (MCID) at the two-year time point was calculated per group using a distribution-based method (MCID = 0.5 * standard deviation of change in scores). Between-group differences in achieving the respective MCID was examined using a Chi Squared test. Two-way repeated measures ANOVAs were conducted to examine the main effects of group and time, and their interaction, on passive ROM and strength in each direction (flexion, abduction, internal rotation, external rotation). If main effects were significant, post-hoc analyses were completed to examine pairwise comparisons. Results: One hundred nineteen participants were included (60 AAGR, 59 Bankart) with an overall average of 10% GBL. Re-dislocation rates were significantly lower in the AAGR group (0%) than the Bankart group (28%) at two-years post-operatively (p<0.001). There was a statistically significant main effect of time (p<0.001), and interaction between group and time (p=0.001), but no main effect of group (p=0.971), on WOSI scores. Pairwise comparisons revealed that within the Bankart group, all post-operative time points had significantly lower (better) WOSI scores compared to pre-operatively (p<0.001), but there were no significant differences between any post-operative time points. Within the AAGR group, there were statistically significant differences between each time-point (Figure 1). The MCID for WOSI scores was calculated to be 12.57 points for the Bankart group and 10.79 points for the AAGR group. Significantly more AAGR patients (89%) than Bankart patients (11%) met the WOSI MCID at two-year follow-up (p=0.041). There were statistically significant main effects of time on passive ROM in the flexion (p<0.001), abduction (p<0.001), internal rotation (p=0.004), and external rotation (p<0.001) directions. There were no statistically significant main effects of group, or interactions between group and time, for any passive ROM direction. Similarly, there were significant main effects of time on strength in flexion (p<0.001), abduction (p<0.001), internal rotation (p<0.001), and external rotation (p<0.001). There were no statistically significant main effects of group, or interactions between group and time, for any strength direction. Conclusions: In this RCT of patients with subcritical GBL, AAGR achieved excellent functional and patient-reported outcomes without incidence of re-dislocations, outperforming arthroscopic Bankart repair at two-years post-operatively. Findings from this study indicate that AAGR is a safe and effective alternative to Bankart repair for individuals with subcritical GBL. Specifically, individuals who underwent AAGR did not experience recurrent instability as seen in the Bankart population, underscoring the effectiveness of AAGR in the presence of subcritical GBL.
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