Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Shoulder Instability Procedures compared!

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Shoulder Instability Procedures compared! · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

0:00
Imagine for a moment you're, say, an ambitious
0:02
cricketer, maybe playing at a high amateur level,
0:05
or perhaps a professional rugby player. You dislocate
0:08
your shoulder. It's painful, obviously, frustrating.
0:10
But you do the recovery, all the physio, you
0:12
build the strength back up. You think, OK, I'm
0:13
clear. But then, thwack, it happens again. And
0:17
maybe again after that. That's the, well, the
0:20
crushing reality of recurrent shoulder instability.
0:23
It's this relentless problem. It doesn't just
0:25
sideline careers. It can really impact your daily
0:27
life, strips away confidence, limits even the
0:30
simple things, that frustration, you know, of
0:32
a part of your body just refusing to stay put.
0:34
It can be immense, huge career implications,
0:37
not just for athletes, but other professionals,
0:39
too. And the emotional toll, of course. Now...
0:43
For far too long, considering how common this
0:45
is, there's been a surprising lack of a clear
0:47
agreed upon gold standard treatment, really quite
0:50
surprising. And this has led to vastly different
0:52
surgical approaches across the world, often influenced
0:55
more by where a surgeon trained or the local
0:57
traditions rather than perhaps what the most
0:59
robust up -to -date evidence actually suggests.
1:02
So today we're embarking on a really insightful
1:05
journey into this critical area of orthopedic
1:07
surgery, an area where, maybe surprisingly, treatment
1:10
decisions have often been shaped by, let's say,
1:13
inherited wisdom and regional habits, our mission,
1:16
it's clear. We want you to gain a crystal clear
1:19
understanding of what the very latest, most comprehensive
1:22
analysis reveals about treating this recurrent
1:24
shoulder instability effectively. We're aiming
1:26
to cut through the noise, bring you the definitive
1:29
insights, and to help us navigate this, well,
1:32
intricate and often debated landscape. We are
1:34
incredibly privileged to be joined today by Professor
1:36
Mo Imam. His deep expertise and importantly,
1:39
his recent significant contributions to synthesize
1:41
the critical evidence in this field are genuinely
1:44
setting new benchmarks for clinical practice.
1:47
Professor, it is an absolute pleasure to have
1:49
you with us for this deep dive. It's genuinely
1:51
a pleasure to be here, a really vital topic to
1:54
explore for patients and clinicians too. Professor,
1:56
before we get into the specific treatments, could
1:59
you maybe help us grasp the sheer scale of this?
2:02
The profound impact of recurrent anterior shoulder
2:06
instability. Who typically gets affected most?
2:09
And crucially, what are the bigger long -term
2:12
implications if it's not properly addressed?
2:15
It sounds like it's much more than just a temporary
2:17
setback. You've hit on a crucial point there.
2:19
Recurrent instability of the shoulder is, well,
2:22
it's far more than a minor issue. It's a truly
2:24
significant, often quite debilitating complication
2:27
after that first dislocation, or even sometimes
2:29
after a less severe subluxation. When you look
2:32
at the statistics, they are quite sobering actually.
2:34
Data shows that up to 60%, six zero of patients
2:37
who have an acute traumatic anterior shoulder
2:39
dislocation will unfortunately go on to suffer
2:42
from recurrent instability. 60%, wow. Yes, it's
2:46
a massive proportion. And what's particularly
2:48
striking, and frankly quite concerning from a
2:50
clinical view, is this inverse relationship with
2:53
age. Put simply, the younger you are when you
2:56
first dislocate your shoulder, the dramatically
2:59
higher your risk of it happening again. To give
3:01
you a concrete example, take a 20 -year -old
3:04
male patient. After their first traumatic anterior
3:07
dislocation, the risk of it happening again can
3:10
be astonishingly high, up to 72%. 72%. Indeed.
3:14
Think about that. Almost three quarters of young
3:16
men in that age group could face this problem
3:18
repeatedly. This figure really highlights that
3:21
this is overwhelmingly a problem affecting young,
3:23
active people, often at the peak of their physical
3:26
activity, whether that's sport or demanding jobs.
3:29
72 % for a 20 -year -old, that's, well, nearly
3:32
three out of four. That's not just a clinical
3:34
statistic, is it? It sounds like a profound,
3:37
almost life -altering risk for someone just starting
3:40
their adult life or, say, building an athletic
3:42
career. It really underscores why just treating
3:45
the first injury isn't always enough. We need
3:48
solutions that truly prevent it happening again.
3:50
Which is exactly what your analysis looks at.
3:52
Uh -huh. Are there specific risk factors, then?
3:55
Things that... makes some people more susceptible
3:57
than others. Absolutely. Beyond age and the,
4:01
you know, traumatic nature of the initial event,
4:03
we've identified several key anatomical and patient
4:06
-specific risk factors. These significantly contribute
4:10
to these high recurrence rates. They include
4:12
specific bony lesions on the shoulder joint surfaces.
4:15
For instance, a hill sex lesion. That's an indentation
4:18
or compression fracture on the back of the humeral
4:20
head, the ball part of the joint. It happens
4:22
when it hits the front of the glenoid socket
4:24
during the dislocation. Then there's the bank
4:26
heart lesion. This is where the labrum, that
4:28
crucial ring of cartilage that deepens the socket,
4:31
gets torn away from the bone. Both of those indicate
4:33
structural damage that basically compromises
4:36
the shoulder's stability. Other factors include
4:39
the patient's sex males often have higher recurrence
4:41
rates. their age, as we just discussed, and the
4:45
presence of what we call hyperlaxity. Hyperlaxity.
4:47
Yes, essentially meaning someone is naturally
4:49
double -jointed or has very flexible joints.
4:52
This predisposes them to instability. These elements
4:55
act as, well, predictors for who might struggle
4:58
with recurrent dislocations. So it's not just
5:01
about the initial pop out of jank. It's about
5:03
underlying structural issues, maybe bone damage,
5:06
maybe torn tissue, and even a person's natural
5:08
joint flexibility. That paints a much clearer
5:11
picture of the vulnerability. And you mentioned
5:13
the impact on patients' lives earlier. Could
5:15
you expand on what disabling affliction really
5:17
means for these young, active people? What's
5:20
the real world consequence? Yes, the term disabling
5:23
affliction is chosen quite deliberately. because
5:26
that's precisely what it can be. For young, active
5:30
patients, athletes especially, this isn't just
5:33
an inconvenience, it can be genuinely career
5:35
-ending. Think about a professional athlete,
5:38
a rugby player needing to make powerful tackles,
5:40
maybe a tennis player serving with force, or
5:43
even just an avid recreational climber who absolutely
5:46
relies on full shoulder stability. If their shoulder
5:49
consistently gives way, they're suddenly unable
5:52
to participate in their sport, their pre -injury
5:54
activities. It fundamentally limits their participation,
5:57
their performance, and often their professional
6:00
livelihood. We often see patients who just can't
6:02
return to their prior level of activity, where
6:04
they live with this constant apprehension, this
6:07
fear of it happening again. That affects their
6:09
mental well -being just as much as their physical
6:11
capacity. It's profoundly limiting. And for our
6:14
discussion today, it's important just to clarify.
6:16
When we use the term instability, we're encompassing
6:19
both subluxation, where the joint partially comes
6:21
out and then goes back in spontaneously, and
6:24
frank dislocation, where it completely separates
6:26
and needs someone to put it back in. We treat
6:29
them as a single clinical entity here, because
6:32
both represent a failure of the shoulder to stay
6:34
stable and can have similar underlying issues
6:37
and long -term consequences. Beyond that immediate
6:40
impact on activity and function, there's a really
6:42
critical long -term consequence, one that often
6:45
gets overlooked, perhaps, but is maybe one of
6:47
the most compelling reasons for definitive treatment.
6:50
Recurrent instability has been positively correlated
6:52
with a significantly increased risk of subsequent
6:55
degenerative joint arthritis, decades later.
6:58
Potentially, yes. What this means is, if these
7:02
recurring dislocations or subluxations aren't
7:04
definitively treated, the cumulative trauma to
7:07
the joint The repeated impact, the wear and tear,
7:10
can lead to premature degeneration of the joint
7:12
surfaces. This can cause debilitating arthritis
7:15
decades down the line, long after their athletic
7:17
careers might have ended. So treating this effectively
7:20
isn't just about getting someone back to sport
7:22
quickly. It's profoundly about protecting their
7:24
long -term joint health and our overall well
7:26
-being. This really underscores why finding the
7:29
optimal evidence -based solution, one that offers
7:31
true long -term stability, is so absolutely crucial,
7:34
both for immediate relief and for sustained quality
7:36
of life. That truly highlights the gravity, doesn't
7:39
it? It sounds like a problem that doesn't just
7:41
impact immediate function, quality of life, but
7:44
casts this long shadow over a patient's joint
7:46
health for decades. It really brings home the
7:49
urgent need for effective, evidence -based solutions,
7:52
not just quick fixes. Given this pressing need,
7:55
Professor, two surgical procedures seem to, well,
7:59
dominate the conversation for definitive treatment,
8:00
the Bancard procedure and the Latarjet procedure.
8:03
Could you walk us through what each of these
8:04
involves? shed some light on why there's such
8:07
a noticeable divide globally in preference for
8:09
one over the other. Certainly. These two are
8:12
indeed the primary surgical options for recurrent
8:15
anterior shoulder instability, and they approach
8:17
the problem from, well, fundamentally different
8:20
anatomical and biomechanical angles. Understanding
8:23
their differences is really key to appreciating
8:25
the debate around them. Let's start with the
8:27
Banker procedure. At its core, this procedure
8:30
is about repairing the damaged soft tissues,
8:33
the bits that were torn during the dislocation.
8:36
Specifically, it involves re -tensioning the
8:38
anterior capsule that's the main ligament structure
8:40
at the front of the shoulder, which can get stretched
8:42
or torn, and crucially the direct repair of the
8:45
ovals labrum. As we discussed, the labrum is
8:49
that vital ring of cartilage around the shoulder
8:51
socket, the glenoid. It deepens it, helps stabilize
8:54
the joint. When the shoulder dislocates, this
8:56
labrum can be torn away from the bone that's
8:58
the specific bankart lesion. Right, the torn
9:01
cartilage ring. Exactly. The procedure typically
9:03
uses strong sutures, or sometimes small absorbable
9:07
suture anchors put into the bone, to reattach
9:10
this torn labrum and tighten up the stretched
9:12
capsule. The aim is basically to restore the
9:15
natural anatomy of the joint. Now the Bankart
9:18
procedure was initially described way back, actually,
9:20
but gained wider recognition and refinement much
9:22
later. It has since evolved so it can be done
9:25
through open surgery, a larger incision, or,
9:28
much more commonly today, arthroscopically. Keyhole
9:31
surgery. Precisely. Using small incisions, a
9:34
tiny camera to see inside the joint, and specialized
9:37
instruments. Its widespread adduction is quite
9:40
remarkable. Historically, something like 90 %
9:43
of surgeons internationally, particularly in
9:44
North America and parts of Europe, have favored
9:46
arthroscopic bankart repair as the first line
9:48
treatment, mainly due to its minimally invasive
9:51
nature and the perception of restoring the anatomy.
9:53
So the bankart is essentially patching up the
9:56
soft tissue damage, like... sewing up a tear,
9:59
really. And it's been the go -to for a long time,
10:01
especially the keyhole version. That makes sense.
10:04
The appeal of less invasive surgery is obvious.
10:07
But what about the Letarjet procedure, then?
10:09
How does that differ? And why is there such a
10:11
strong alternative preference in some places?
10:14
That's a perfect segue. Because in stark contrast,
10:17
we have the Letarjet procedure. Sometimes it's
10:20
more descriptively called the coracoid bone block
10:23
procedure. This is a more involved surgical technique.
10:27
It addresses not just the soft tissue damage,
10:30
but also, and this is critical, potential bone
10:33
loss or significant structural deficiencies around
10:36
the glenoid socket itself. It involves transferring
10:39
a specific piece of the coracoid process that's
10:42
a small, hooked bit of bone that normally sits
10:44
off the shoulder blade along with its attached
10:46
conjoined tendon, which includes parts of the
10:48
biceps and corcabrachialis muscles. Okay, so
10:50
you're actually moving a piece of bone. Exactly.
10:53
This bone block, with the tendon still attached,
10:56
is then precisely positioned and secured with
10:58
screws onto the front rim of the glenoid socket.
11:01
It essentially extends and reinforces the socket
11:04
forwards. The mechanism here is ingenious, really.
11:07
It's twofold. Firstly, it creates a physical
11:10
bony block, a buttress if you like. It physically
11:13
stops the humeral head from slipping forward
11:15
out of the joint. Secondly, those transferred
11:17
muscles, which stay attached to the moved bone,
11:20
provide a dynamic stabilizing effect. So when
11:22
the arm moves into positions where it might normally
11:25
dislocate, these muscles contract, pulling the
11:27
humeral head back into the socket, an extra layer
11:30
of stability. This procedure was initially described
11:32
by Dr. Michel Letargette back in 1954, and he
11:35
later modified it in 1980. Now what's truly fascinating
11:39
about the Letargette is its very distinct geographical
11:41
preference. While Benkart dominates in many regions,
11:44
you see this stark contrast in places like France.
11:47
For example, our research indicates that an astonishing
11:49
72 % of French shoulder surgeons prefer the Letargette
11:53
procedure as their first -line treatment. 72
11:55
% compared to 90 % internationally favoring Benkart.
11:58
Precisely. It truly illustrates the powerful
12:02
influence of tradition, surgical training environments,
12:05
local schools of thought on established surgical
12:07
practice. often more so than global consensus
12:10
based purely on evidence. That is a staggering
12:13
regional difference. It's almost like different
12:15
medical dialects have evolved over time, and
12:18
this brings us perfectly to what you've termed
12:19
the consensus gap. Could you elaborate on this
12:22
core problem? How has it impacted treatment decisions,
12:25
especially given the historical limitations in
12:28
the available research you mentioned? Exactly.
12:31
This geographical divergence really brings us
12:33
to the heart of this consensus gap. A situation
12:36
where there's no universally agreed upon gold
12:39
standard treatment. The core problem has been
12:42
that the choice of which surgery to perform has
12:44
largely been based on a surgeon's training background,
12:47
their personal experience, maybe the prevailing
12:50
traditions within their region or hospital, rather
12:52
than on robust, high -level comparative evidence.
12:56
This has led to significant variation in care.
12:58
And frankly, it's left many patients, and indeed
13:01
clinicians, without a definitive answer on what
13:04
the optimal approach truly is. For a long time,
13:07
the academic challenge was made worse by inherent
13:09
limitations in the published literature. Many
13:11
prior studies were restricted to older retrospective
13:14
reviews looking back at patient data, or perhaps
13:16
single surgeon series, where one surgeon reports
13:19
on their own patients. Now, while these studies
13:21
can give valuable initial insights, they inherently
13:24
carry significant risks of confounders, other
13:26
factors that might skew the outcomes and bias.
13:29
Right, like maybe surgeons choosing LaTarget
13:31
only for the really bad cases. Exactly, that
13:33
sort of thing. A surgeon might unconsciously
13:36
select Bancart for less severe cases and LaTarget
13:39
for more complex ones, which makes a direct comparison
13:41
unreliable. Such studies, while useful, couldn't
13:45
definitively or systematically compare the efficacy
13:48
of these two very different procedures in a truly
13:50
unbiased way. This situation starkly underscored
13:54
the critical need for a more comprehensive and
13:56
systematic analysis. One that looks at all the
13:59
existing evidence, carefully pooling the data
14:02
to really understand which procedure offered
14:04
the best, most durable outcomes for patients
14:06
across the board. That's the gap our work aimed
14:09
to fill. That deeply entrenched preference, almost
14:11
like an inherited surgical philosophy, is really
14:14
eye -opening, especially when science could potentially
14:16
offer a clearer path. It makes the kind of rigorous
14:19
analysis you've conducted even more vital for
14:22
orthopedic professionals, for anyone trying to
14:24
make the absolute best decisions for patients.
14:26
So let's talk about that path. How exactly did
14:28
you and your team go about rigorously comparing
14:31
these two procedures? How did you try to cut
14:33
through that traditional bias and give us more
14:35
definitive answers? What was the methodology
14:37
behind this deep dive? That's a critical question
14:40
because the strength and reliability of our conclusions
14:43
fundamentally hinge on the meticulousness, the
14:47
rigor of our methodology. Our study was designed
14:50
as a systematic review and meta -analysis. For
14:53
those unfamiliar, this is generally considered
14:54
the highest level of evidence when you're synthesizing
14:57
existing research. It involves a structured,
15:00
comprehensive search for all relevant studies
15:02
on a topic, followed by a statistical pooling
15:04
of their results. It represents, to date, the
15:07
largest and most up -to -date comparison of these
15:09
two specific procedures, Bankert versus Letarget
15:13
in the published literature. To give you a sense
15:15
of the sheer volume, the statistical power of
15:17
the data we examined, our analysis pooled information
15:20
from seven distinct cohort studies. These are
15:23
studies that follow groups of patients over time.
15:25
Collectively, these studies involved a substantial
15:27
total of 300 -275 patients. Over 3 ,000 patients.
15:32
That's significant. It is. To break that down
15:34
further, 2 ,791 individuals had undergone the
15:38
Bancart repair, while 484 had the Laddarjet procedure.
15:42
This extensive patient population allowed us
15:46
to conduct a truly robust, powerful examination
15:49
of the comparative outcomes. It gives our findings
15:52
significant statistical weight. Our search strategy
15:55
was incredibly comprehensive, designed to capture
15:58
virtually all relevant studies published up to
16:00
January 2018. We systematically searched across
16:03
all the major medical and scientific databases.
16:06
PubMed, Cochrane Central Register -controlled
16:08
trials, Scopus, Ovid, web of science, this broad
16:12
systematic approach was absolutely essential
16:14
to ensure we didn't miss any pertinent research
16:16
and thus reduce the risk of what's called publication
16:18
bias, where studies with certain results might
16:20
be more likely to get published than others.
16:22
So you cast a really wide net, gathered all the
16:24
relevant data. Once you had all these studies,
16:26
how did you then go about aggregating and analyzing
16:28
such different types of data? You mentioned things
16:30
like operative time versus whether someone got
16:32
an infection. How do you compare those statistically?
16:35
That's a great question. It's all about matching
16:37
the right statistical tool to the nature of the
16:40
data we were analyzing. For what we call continuous
16:43
data, things like operative time, measured in
16:45
minutes, or patient -reported outcome scores,
16:48
like the Rose score, which are numerical scales,
16:51
we pool these as mean differences. This simply
16:54
allowed us to calculate the average difference
16:56
in these measures between the two groups, the
16:58
Bankart group and the Letarjet group. So for
17:01
example, we could see if one procedure on average
17:03
took significantly longer or resulted in a higher
17:06
average score. But for dichotomous data, that
17:08
is, outcomes that either happened or didn't,
17:11
a yes or no event, things like whether the shoulder
17:13
experienced another recurrence, if a revision
17:15
surgery was needed, if there was a full redislocation,
17:18
the development of arthropathy, or complications
17:20
like infection or hematoma. The binary outcome.
17:23
Exactly. For those, we pooled the results as
17:26
risk ratios, often abbreviated RR, with 95 %
17:30
confidence intervals. Our risk ratio is a very
17:33
powerful measure. It tells us how many times
17:35
more likely an event was in one group compared
17:37
to the other. For instance, if the risk ratio
17:39
for recurrence was, say, 2 .5, it would mean
17:42
that recurrence was two and a half times more
17:44
probable in one surgical group compared to the
17:46
other. The 95 % confidence interval just gives
17:49
us a range of certainty around that estimate.
17:51
Now, to ensure the utmost methodological rigor
17:54
and to minimize any potential bias throughout
17:56
this complex process, we adhered strictly to
17:58
the PRISMA guidelines. These are the internationally
18:01
recognized standards, a checklist really, for
18:03
histomatic reviews and meta -analyses. They ensure
18:06
transparency and reproducibility. Our eligibility
18:09
screening process, deciding which studies to
18:11
actually include, involved two meticulous steps.
18:14
Each step was conducted independently by three
18:16
experienced reviewers. Yes, that redundancy helps
18:20
ensure that studies are included or excluded
18:23
consistently and objectively. It prevents any
18:26
single reviewer's potential bias from influencing
18:28
the selection. Similarly, the crucial task of
18:31
data extraction, pulling out all the relevant
18:34
numbers and facts from the selected studies,
18:36
was performed independently by three different
18:38
authors. Any disagreements at either stage, screening,
18:42
or extraction were thoroughly discussed and resolved
18:44
by consensus among the reviewers. This multi
18:47
-reviewer approach is vital for building confidence
18:49
in the dataset. Furthermore, we rigorously assess
18:53
the quality of each included study using the
18:55
Newcastle -Ottawa scale. This is a widely respected
18:58
tool that evaluates studies based on three key
19:00
things. How carefully the study participants
19:02
were selected, how comparable the groups were
19:04
for important factors that could influence outcomes,
19:06
and how robustly the outcomes themselves were
19:08
measured. The included cohort studies in our
19:11
meta -analysis achieved a high mean score of
19:13
8 out of 9 possible points on this scale. That
19:15
sounds very good. It is, yes. It's an excellent
19:18
indicator. It means they were generally of good
19:20
methodological quality, which further strengthens
19:22
the credibility and reliability of our pooled
19:25
results. Finally, and this is where our analysis
19:28
perhaps made a particularly vital contribution,
19:31
we placed a crucial focus on follow -up time.
19:33
This was critical because previous analyses hadn't
19:36
systematically looked at how the differences
19:38
in outcomes between the two procedures might
19:41
evolve, might change over time. There was a growing
19:44
body of newer evidence suggesting that the true
19:46
long -term advantage of one procedure over the
19:48
other might only become really clear with longer
19:51
observation periods, not just looking at immediate
19:53
post -op results. Right. Things might look similar
19:56
early on, but diverge later. Precisely. Our included
20:00
studies had follow -up periods ranging from as
20:02
short as just 30 days right up to as long as
20:03
10 years. This broad range allowed for a truly
20:07
comprehensive long -term analysis, especially
20:10
using what we call subgroup analysis based on
20:12
different follow -up durations. This temporal
20:15
dimension allowed us to see if, for example,
20:16
a procedure that seemed comparable in the short
20:19
term might actually be significantly less effective,
20:21
or even fail more often, in the long run. It
20:24
paints a much more complete picture of durability.
20:26
That's a truly impressive level of methodical
20:28
investigation, Professor. It really underscores
20:31
why your findings carry so much weight moving
20:33
beyond maybe anecdotal experience or single studies
20:36
to what the collective evidence truly shows.
20:39
Now, let's get to those critically important
20:41
results. For patients, and indeed for clinicians,
20:45
the ultimate measure of success in shoulder stabilization
20:47
surgery often boils down to one thing, preventing
20:50
the shoulder from dislocating again. What did
20:52
your rigorous analysis reveal regarding recurrence
20:54
and redislocation rates for bankart versus latarjet?
20:57
Were there any surprises? This is indeed the
20:59
most critical finding for everyone involved,
21:02
and our analysis revealed a very clear, I would
21:05
say quite stark difference. When we looked at
21:08
overall recurrence rates, and by recurrence,
21:11
remember, we mean any instance of the shoulder
21:13
feeling unstable, whether it was a minor subluxation
21:16
or a full dislocation after the surgery, the
21:18
findings were absolutely compelling. The arthroscopic
21:21
bankart procedure was consistently associated
21:23
with a significantly higher risk of recurrence
21:26
compared to the Letarjet procedure. Specifically,
21:29
the risk ratio, the RR, was 2 .87, and the P
21:33
value was very low. less than 0 .0001 indicating
21:37
high statistical significance. 2 .87. So what
21:41
does that mean in practical terms? In practical
21:43
terms, it means the patients undergoing a bank
21:45
cart repair were nearly three times more likely
21:48
to experience some form of recurrent instability
21:50
compared to those who had the latarjet procedure.
21:53
Wow. Nearly three times more likely. Exactly.
21:56
That is a substantial and crucially a statistically
21:58
highly significant difference. It's not a marginal
22:01
variation. It's a profound distinction in the
22:03
stability offered. Okay, that's dramatic for
22:06
overall recurrence. And how did that play out
22:08
for actual full -blown dislocations? Was the
22:10
pattern similar there? Precisely. The pattern
22:13
was strikingly similar, reinforcing that initial
22:15
finding. When we focused specifically on overall
22:18
redislocation rates, which refers to the shoulder
22:21
fully coming out of the socket again, the picture
22:23
was equally clear. Arthroscopic bank art was
22:26
also strongly linked to a higher risk of actual
22:29
redislocation with a risk ratio of 2 .74 and
22:32
a p -value of 0 .03. Again, this indicates a
22:35
substantial and clinically meaningful difference
22:37
in the long -term stability offered by the two
22:39
procedures. Now, here's where our study makes
22:42
perhaps its most significant contribution. Understanding
22:45
the long -term perspective. We specifically focused
22:48
on how these outcomes changed over time, because
22:51
as you said, short -term success isn't always
22:52
the whole story. What we discovered was that
22:55
the pronounced advantage for the Letarge procedure
22:57
in preventing recurrence became most evident
22:59
with longer follow -up periods. This difference
23:02
became particularly clear and statistically robust
23:04
between six and ten years post -operatively.
23:07
Six to ten years later. Yes. In that extended
23:10
window, the risk ratio for recurrence with Bankart
23:13
actually escalated to 3 .00. Just three times
23:16
the risk again in the long run? It's exactly.
23:19
After six to ten years, Patients who underwent
23:21
a Bancart repair were truly three times more
23:24
likely to experience their shoulder coming out
23:26
again compared to those who had a Latarjet. This
23:29
isn't a small, fleeting difference. It's a sustained,
23:32
powerful, and durable long -term benefit seen
23:34
with the Latarjet procedure. And we observed
23:37
an identical, concerning trend for full redislocation
23:40
as well. The higher redislocation rate for arthroscopic
23:44
Bancart also became particularly evident in that
23:46
six - to ten -year postoperative window. with
23:49
a risk ratio of 2 .85. This consistent pattern,
23:53
across both recurrence and redislocation, especially
23:56
when observed over a longer time horizon, strongly
23:59
suggests something important. It suggests that
24:01
while a bankrupt repair might hold up reasonably
24:03
well in the very short term, its effectiveness
24:05
in maintaining definitive stability significantly
24:08
diminishes over the medium to long term, when
24:10
you directly compare it to the lethargic procedure.
24:12
It's important mention, just for full transparency,
24:15
that one single study within our analysis did
24:17
show no significant difference between the procedures
24:19
at the one to five year mark. Okay, an outlier.
24:22
Yes, but it's crucial to understand that this
24:24
single outlier doesn't diminish the robust overall,
24:28
and particularly the long -term trends we observed
24:30
from the pooled data across all the included
24:33
studies. The overwhelming evidence, especially
24:35
looking at that broader time horizon in the large
24:37
patient population, clearly points to the Latarjet
24:40
procedure offering superior sustained long -term
24:42
stability. This is a critical insight. So the
24:45
long -term data really paints a very clear, quite
24:47
compelling picture then. While both procedures
24:49
are aiming to stabilize the shoulder, The Latarjet
24:52
appears to offer this distinct, lasting advantage
24:54
in keeping the shoulder definitively in place,
24:57
particularly years down the line. That's a powerful
24:59
and practical insight for anyone considering
25:01
these options, especially those young, active
25:04
individuals wanting to get back to high -level
25:05
activity without that constant fear of it happening
25:08
again. Now, while stability is paramount, patients
25:11
obviously worry about the trade -offs, particularly
25:14
complications and overall functional recovery.
25:17
There's a common perception, I think, that perhaps
25:19
more invasive procedures like lethargia might
25:21
carry inherently higher risks. What did your
25:24
meta -analysis truly reveal about complications?
25:27
Things like infection, hematoma, maybe issues
25:30
with the screws or anchors, and perhaps even
25:32
more importantly, how do the two procedures compare
25:34
in terms of patient -reported functional outcomes,
25:37
those scores that often reflect quality of life
25:39
after surgery? That's an excellent point and
25:41
a very common concern. Our findings on complications
25:44
really do challenge some long -held perceptions,
25:47
which is, in itself, a significant takeaway from
25:50
our work. When we meticulously looked at various
25:52
surgical complications, the picture was, as you
25:55
hinted, quite nuanced and often surprising. For
25:58
instance, regarding infection. Our analysis presented
26:00
a genuinely surprising finding. The Bancart procedure
26:03
was actually associated with a lower risk of
26:05
infection compared to Letarget. The risk ratio
26:08
was 0 .16, with a statistically significant p
26:11
-value of 0 .0002. Lower risk with Bancart? That
26:14
is surprising. It is. It means Bancart patients
26:17
were considerably less likely to develop a post
26:20
-operative infection based on this data. Now,
26:23
it's vital to acknowledge a limitation here.
26:25
The number of studies reporting specifically
26:27
on infection was relatively small, only three,
26:30
and the definitions of infection weren't entirely
26:32
standardized across them. However, based on the
26:35
available evidence, it does suggest this is a
26:37
real, albeit potentially small in absolute terms,
26:41
difference. It's certainly a point for surgeons
26:44
to be particularly mindful of with the Lodgett.
26:46
However, when we examined other anticipated complications,
26:50
that common perception about latarjet being inherently
26:52
riskier simply didn't hold up in the aggregated
26:55
data. For hematoma formation, that's a collection
26:57
of blood near the surgical site, we detected
26:59
no significant difference between the two procedures.
27:02
The risk ratio was 0 .20. Similarly, a specific
27:06
concern often raised about latarjet relates to
27:08
screw -related complications, given it involves
27:10
fixing a bone block with screws. Right. You'd
27:13
think that might cause more issues. You might.
27:15
But our analysis found no significant difference
27:17
in screw or anchor -related complications between
27:20
the two procedures. The risk ratio was 0 .17.
27:24
This suggests that the presence of screws for
27:26
Letarjet does not, on the whole, lead to a higher
27:29
rate of implant issues compared to the anchors
27:31
used in Bankart. So when we synthesize the overall
27:34
complication profile, it becomes quite clear.
27:37
Contrary to perhaps popular belief or historical
27:39
apprehension, our comprehensive review demonstrated
27:42
no significant difference in most major treatment
27:45
-related complications. Beyond that specific,
27:48
albeit small, observed difference in infection
27:50
rates. This is a crucial finding. It can profoundly
27:54
inform patient counseling. It suggests that the
27:56
superior long -term stability offered by Letarget
27:58
does not generally come with a higher burden
28:00
of overall complications. That's a very powerful
28:03
message for patients and surgeons. That's a huge
28:05
finding, honestly. Challenging what many might
28:08
instinctively believe about more complex procedures
28:10
versus simpler ones. It implies the benefits
28:13
of liturgy and stability aren't necessarily offset
28:16
by a higher risk of adverse events overall. What
28:19
about the long -term health of the joint itself?
28:21
The development of arthritis? That's a major
28:23
concern for patients looking decades ahead. You're
28:26
right. Long -term joint health is absolutely
28:28
paramount. Moving to long -term arthropathy or
28:31
the development of degenerative joint arthritis,
28:33
this was another rather unexpected outcome based
28:36
on the available data. Primarily reported in
28:39
one key study within our analysis, we found no
28:42
significant statistical difference between Bankart
28:44
and Letarget procedures in the likelihood of
28:46
developing progressive arthropathy. The risk
28:49
ratio was 0 .34. No difference in arthritis risk.
28:51
Right. Despite the difference in instability.
28:54
Exactly. And this is perhaps surprising, especially
28:57
when you recall our earlier discussion about
28:59
the known strong positive correlation between
29:02
recurrent instability and the risk of subsequent
29:04
arthritis. Logically, given bankart repair was
29:07
linked to significantly higher ongoing instability,
29:10
one might intuitively expect it to lead to more
29:13
arthropathy over time due to that continued microtrauma.
29:17
Makes sense. So why wasn't that seen? Well, one
29:20
potential explanation might relate to the maximal
29:22
follow -up periods of the studies included. While
29:25
up to 10 years is substantial, the onset of clinically
29:27
significant symptomatic arthropathy might often
29:30
occur beyond that 10 -year mark, meaning we might
29:33
not have captured its full progression within
29:35
this dataset. It could also be influenced by
29:37
other patient factors not consistently captured
29:39
across all studies. Or perhaps the early signs
29:42
of arthropathy are simply too subtle to be universally
29:45
detected and reported within these study designs.
29:48
It's an area that clearly warrants longer -term,
29:51
dedicated follow -up studies. That's a fascinating
29:53
paradox, then. More instability, but not necessarily
29:56
more measured arthritis within the study's time
29:59
frame. It really forces us to think about how
30:02
long long -term truly needs to be when evaluating
30:05
these outcomes. And speaking of outcomes, let's
30:08
turn to the patient reported outcomes, specifically
30:10
using the Rho score. This is often seen as the
30:13
patient's voice in research. What did you find
30:15
there, especially given the clear stability differences
30:18
you've already presented? This is where things
30:20
get particularly interesting and frankly quite
30:22
nuanced. It reveals a critical point about how
30:25
we actually measure success in these cases. Our
30:28
analysis found no significant difference in patient
30:30
-reported outcomes as measured by the Rho score
30:33
between the two procedures. This is despite the
30:35
glaring significant difference in objective and
30:38
stability rates we just discussed. No difference
30:40
in the Rho score. How can that be? Exactly. The
30:43
mean difference was a mere 0 .22. with a p -value
30:46
of 0 .94, indicating virtually no statistical
30:49
difference at all. This apparent paradox demands
30:52
a deeper look. To understand this, we need to
30:54
delve into the row score itself. The row score,
30:57
first published back in 1978, is a physician
31:00
-led tool. It's designed to assess a patient's
31:03
shoulder across three key areas. Its stability,
31:06
its range of motion, and overall function. While
31:09
it aims to give a picture of patient satisfaction
31:11
and outcome, it has certain nuances, critical
31:14
limitations, that can obscure the true picture.
31:17
Critically, the Rho score is heavily weighted
31:19
towards the stability variable. Heavily weighted
31:21
towards stability. Yes. This means if a patient
31:23
experiences even occasional residual subluxation,
31:26
maybe a clunking sensation, even if they have
31:28
excellent range of motion and feel functionally
31:30
quite good in their daily activities, that instability
31:32
component will significantly drag their overall
31:35
Rho score down. It can make the score appear
31:36
poor or fair, even if other aspects are good.
31:40
It's almost like a pass fail on stability that
31:43
can inadvertently overshadow other functional
31:45
improvements. If a shoulder has any instability,
31:48
even if it feels quite good to the patient in
31:50
terms of movement, the score gets penalized heavily.
31:53
And you mentioned earlier there are different
31:55
versions of this score floating around. That
31:57
sounds like it could muddy the waters even further.
31:59
Exactly right. You've captured the essence of
32:00
the paradox. It can be quite unforgiving on that
32:03
stability component. And that single aspect can
32:06
indeed overshadow other functional gains. And
32:09
yes, a major persistent problem in the orthopedic
32:12
literature is that there are actually four different
32:15
versions of the Rowe score, published over the
32:17
years with subtle but sometimes significant changes
32:19
made in 1978, 1981, 1982, and 1988. Unfortunately,
32:25
studies often don't specify which specific version
32:28
they use when reporting their results. This inherent
32:31
lack of standardization in the reporting tool
32:33
itself makes direct comparisons of row scores
32:35
across different studies incredibly problematic.
32:38
It can quite literally obscure genuine underlying
32:41
differences in stability when only the combined
32:44
overall score is reported. Secondly, another
32:46
reason for the similar row scores, despite objective
32:49
stability differences, could simply be if the
32:51
function and mobility components of the score
32:53
were significantly similar between the two groups.
32:55
If patients in both the Bancard and Letarget
32:58
groups regain excellent range of motion and were
33:01
able to perform daily tasks with similar ease,
33:04
these components, even if stability differed,
33:06
might influence the overall score sufficiently
33:08
to mask that underlying difference in stability
33:11
when you just look at that single combined row
33:14
number. This truly highlights that functional
33:17
outcome is a complex, multifaceted measure. A
33:21
similar composite score doesn't necessarily mean
33:23
the underlying stability problem has been addressed
33:25
with equal effectiveness. It's a key lesson in
33:28
interpreting these outcome measures carefully.
33:31
Finally, just briefly regarding operative time.
33:33
One study within our review did report on this.
33:35
It found that arthroscopic bankart was associated
33:38
with a shorter operative time by about 225 minutes.
33:41
Shorter time for bankart. Yes, but this finding
33:44
was based on limited data from just that one
33:46
study. So while we noted it, it doesn't carry
33:49
the same statistical weight or generalizability
33:52
as our more broadly pooled data for recurrence
33:55
and complications. An interesting point, but
33:58
needs more robust evidence, really. That's a
34:01
vital distinction, Professor. It really underscores
34:03
that functional outcome is complex. We can't
34:06
just rely on a single composite score number.
34:09
While a patient's reported satisfaction or perceived
34:11
function might seem similar, the underlying stability
34:13
can differ profoundly, with potential implications
34:16
over a very long timeline that a single score
34:19
might not fully capture. It certainly makes you
34:21
think critically about how we define and measure
34:24
true surgical success. Now, while this comprehensive
34:27
analysis is incredibly insightful, providing
34:29
very clear trends, as you've mentioned, no single
34:32
study tells the entire story. What were some
34:34
of the limitations or nuances you encountered
34:36
in the available evidence? Things that prevented
34:39
an even clearer, more definitive picture? And
34:41
crucially, what important questions still remain
34:43
for future research in this field? That's an
34:45
absolutely crucial point to address. No study,
34:48
no matter how rigorous, is entirely without its
34:51
limitations. Understanding these nuances is key
34:54
to interpreting the findings correctly and, perhaps
34:57
even more importantly, guiding future research
35:00
efforts. The primary limitation we encountered
35:02
was the inherent level of evidence in the existing
35:04
literature. While we meticulously selected only
35:07
well -conducted studies, the included literature
35:10
largely consists of Level 3 quality evidence,
35:12
primarily cohort studies. Ideally, for truly
35:15
definitive, unassailable conclusions, especially
35:17
when comparing two different surgical procedures
35:19
like this, we would prefer randomized controlled
35:21
trials, RCTs, level 1 evidence. The gold standard
35:24
for comparison. Exactly. RCTs are specifically
35:27
designed to minimize bias by randomly assigning
35:30
patients to different treatment groups. This
35:32
ensures any differences observed are truly due
35:35
to the intervention itself, not other confounding
35:37
factors. With cohort studies, there are inherent
35:41
weaknesses and risks of bias that, despite our
35:44
best efforts in the meta -analysis, cannot be
35:46
entirely eliminated. Our systematic review synthesizes
35:49
the best available evidence, but it can only
35:52
ever be as strong as the underlying studies it
35:54
incorporates. Ideally, we'd want more level 1
35:57
evidence from well -designed RCTs. Another significant
36:00
nuance that introduced complacity was the variability
36:03
in the surgical techniques themselves. Even within
36:06
the broadly defined bankard and letterjet procedures,
36:09
there was a surprising lack of standardization
36:11
in the exact operative techniques used across
36:13
the various studies. For instance, with latarjet,
36:16
this could involve subtle but potentially impactful
36:18
variations, like the precise position of the
36:21
coracoid bone block, or the number and type of
36:23
screws used to fix it. Similarly, for bank card
36:25
repairs, we saw variations in the number or type
36:28
of suture anchors used, or exactly how the capsule
36:31
was handled during the repair. Furthermore, some
36:33
studies even included patients who underwent
36:36
additional or combined procedures. Ah, mixing
36:39
things up even more. Precisely. For example,
36:42
some bank card patients might have also had additional
36:44
capsular imprecation, a tightening of the capsule.
36:47
Or some latar jet groups included patients who
36:49
had concomitant capsular shifts. or even a few
36:52
patients who underwent both letarget and bankart
36:55
repairs simultaneously. This makes direct, truly
36:59
apples -to -apples comparisons more challenging.
37:01
The specific surgical intervention wasn't always
37:04
uniformly applied, introducing some heterogeneity
37:07
that's difficult to fully account for. That's
37:09
a fascinating point about the subtle variations
37:11
in technique. It's almost like different chefs
37:13
using slightly different ingredients or methods
37:15
for the same basic recipe. And you also mentioned
37:18
patient heterogeneity and unreported data. That
37:20
sounds like a major challenge for robust comparison.
37:22
How did that impact your ability to draw even
37:25
more precise conclusions? Indeed, patient heterogeneity
37:29
and the sheer amount of unreported data proved
37:31
to be a crucial and complex limitation. This
37:35
is where selection bias becomes a significant
37:37
concern that we couldn't fully mitigate. Many
37:40
of the included studies simply did not provide
37:42
detailed information regarding the severity of
37:44
the instability. For example, precisely how many
37:47
dislocations a patient had experienced before
37:49
surgery, or, critically, the presence and extent
37:52
of associated pathology. This includes vital
37:54
anatomical factors like the presence and size
37:57
of hill -sax lesions on the humeral head, or
37:59
the presence and magnitude of bony bank cart
38:01
lesions where there's actual bone loss from the
38:03
glandoid rim itself. And that missing data is
38:05
really important. absolutely vital because it
38:08
raises the strong possibility that the LATR -JET
38:10
procedure might have been preferentially performed
38:12
for patients with more severe instability or
38:16
for those with significant co -existent bone
38:18
pathology. In clinical practice, Latarget is
38:21
often reserved for these more complex scenarios
38:24
where a soft tissue repair alone, like Bankart,
38:27
might not be sufficient. Now, if Latarget was
38:30
indeed consistently applied to these more challenging
38:33
cases, then the superior outcomes we observe
38:35
for Latarget in preventing recurrence might actually
38:38
be an underestimation of its true advantage for
38:40
these particularly difficult presentations. Right.
38:42
It might be even better than the numbers show
38:44
for those specific cases. Potentially. Or, conversely,
38:48
it might simply suggest that Letterjet is inherently
38:51
better suited for those more severe anatomical
38:53
presentations, which would be a valuable insight
38:56
in itself, but one that the current aggregated
38:59
data doesn't fully allow us to unpack with absolute
39:02
certainty. To highlight this further, it's particularly
39:05
frustrating that numerous included studies did
39:07
not report the magnitude of glenoid bone loss.
39:09
This is a critical piece of information. Glenoid
39:11
bone loss is a strong discriminator in clinical
39:14
practice when deciding the appropriate surgical
39:15
strategy. Without this detail, our ability to
39:19
fully contextualize the results and draw definitive
39:21
conclusions about patient -specific suitability
39:23
for each procedure is significantly limited.
39:25
So in essence, the Latarject group might have
39:28
comprised patients with more challenging conditions
39:30
to begin with. which makes its superior stability
39:33
finding perhaps even more compelling. Or maybe
39:35
it just highlights its specific utility for those
39:38
very cases. That adds really important layers
39:40
of nuance to the findings. It shows that while
39:43
the trends seem clear, the complexities of individual
39:45
patient factors, subtle surgical variations,
39:48
always need to be meticulously considered when
39:50
translating research into actual clinical practice
39:53
for an individual. And it certainly sets the
39:55
stage for where future deep dives might take
39:58
us. Are there any other major unanswered questions
40:01
that weren't covered in your current scope. Absolutely.
40:04
Finally, an important unanswered question, though
40:06
it is beyond the specific scope of this meta
40:08
-analysis, is the critical aspect of return to
40:11
sport. For young, active patients affected by
40:14
shoulder instability, particularly professional
40:17
athletes or those with high -demand occupations,
40:20
a primary concern isn't just overall stability
40:22
or general function, but crucially, the ability
40:25
to return to their specific sporting activities.
40:27
And perhaps even more importantly, to return
40:30
to their pre -injury level of competition and
40:32
performance without fear of re -injury. A huge
40:35
factor for them. Immense. While our review focused
40:38
on objective stability and broad functional scores,
40:41
this specific area of return to sport, particularly
40:43
at a high level, and the comparative outcomes
40:46
between Bancart and LaTargeette in that regard,
40:48
is a vital consideration. It requires further
40:50
dedicated systematic review, the very practical,
40:53
patient -centric question that we don't yet have
40:56
definitive answers for in a truly comparative
40:58
sense. This really does add important layers
41:00
of nuance. It shows that while the trends are
41:03
clear, Those complexities, individual patient
41:06
factors, surgical variations, specific functional
41:09
goals like sport, always need careful consideration
41:12
when translating broad research into precise
41:15
individualized clinical practice. And it certainly
41:17
sets the stage for where future deep dives might
41:20
take us perhaps into that fascinating area of
41:22
return to sport. So to tie it all together then,
41:26
what we've unpacked today through this extensive
41:28
and meticulous analysis is that while both the
41:30
Bankhart and Letarjet procedures are certainly
41:32
effective at preventing recurrence and optimizing
41:35
shoulder function, the Letarjet procedure consistently
41:38
demonstrates a distinct and really quite significant
41:41
advantage in maintaining robust shoulder stability,
41:44
particularly over the longer term, specifically
41:46
between that six and 10 year mark post surgery.
41:49
Importantly, the superior stability does not,
41:51
for the most part, seem to come with a significantly
41:53
higher burden of most post -operative complications,
41:55
although we did note that slightly higher risk
41:57
of infection, specifically with La Tarjet. This
42:00
deep dive, we hope, offers you a direct shortcut
42:03
to understanding the latest, most comprehensive
42:06
evidence in this critically important field.
42:08
It should empower you, hopefully, to confidently
42:11
engage with discussions around shoulder instability
42:13
treatment. Whether you're a healthcare professional
42:16
striving for optimal patient outcomes, maybe
42:18
an athlete navigating these challenging decisions,
42:20
or simply someone looking to stay exceptionally
42:23
well -informed about leading medical advances.
42:25
If you found this deep dive valuable, we'd be
42:28
incredibly grateful if you'd consider rating
42:30
and sharing it with someone who might also benefit
42:32
from these vital insights. Given the nuances
42:34
we've discussed today, those fascinating historical
42:36
preferences shaping practice, the compelling
42:39
new data on long -term stability, and indeed
42:41
the remaining gaps in understanding exactly how
42:44
patient -specific factors, anatomy, lifestyle
42:47
demands, truly influence individual outcomes.
42:50
The ongoing challenge for clinicians isn't just
42:52
knowing which procedure is generally more effective
42:54
overall. It's about truly discerning for whom
42:57
each procedure offers the most profound and lasting
43:00
benefit. This comprehensive evidence serves as
43:03
a crucial compass guiding us towards better practice.
43:07
But the art of medicine, as always, continues
43:08
to demand a thoughtful, individualized interpretation
43:11
of unique patient needs against the backdrop
43:14
of the most robust scientific findings available.
43:17
It's a continuous journey, really, of learning
43:19
and refinement. A truly thought -provoking conclusion,
43:22
Professor, and a perfect reminder that that journey
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of learning, of applying the best evidence, never
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truly ends. Thank you so much for joining us
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for this deep dive today. We look forward to
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our next exploration with you.