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