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J Shoulder Elbow Surg (2011) -, 1-7

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Bristow-Latarjet and Bankart: a comparative study of shoulder stabilization in 185 shoulders during a seventeen-year follow-up
Lennart Hovelius, MD, PhDa,b,*, Ola Vikerfors, MDc, Anders Olofsson, MDb, Olle Svensson, MD, PhDa, Hans Rahme, MD, PhDd
a b

Division of Surgery and Perioperative Science, Department of Orthopedics, Ume University Hospital, Ume Sweden a a, Department of Orthopedics, Gvle Hospital, Gvle, Sweden a a c Orthopedic Department, Vster Hospital, Vster Sweden a as a as, d Department of Orthopedics Elisabeth Hospital, Uppsala, Sweden
Background: In 2 Swedish hospitals, 88 consecutive shoulders underwent Bankart repair (B), and 97 consecutive shoulders underwent Bristow-Latarjet repair (B-L) for traumatic anterior recurrent instability. Materials and methods: Mean age at surgery was 28 years (B-L group) and 27 years (B group). All shoulders had a follow-up by letter or telephone after a mean of 17 years (range, 13-22 years). The patients answered a questionnaire and completed the Western Ontario Shoulder Index (WOSI), Disability of Arm Shoulder and Hand (DASH), and SSV (Simple Shoulder Value) assessments. Results: Recurrance resulted revision surgery in 1 shoulder in the B-L group and in 5 shoulders in the B group (P .08). Redislocation or subluxation after the index operation occurred in 13 of 97 B-L shoulders and in 25 of 87 of B shoulders (after excluding 1 patient with arthroplasty because of arthropathy, P .017). Of the 96 Bristow shoulders, 94 patients were very satised/satised compared with 71 of 80 in the B series (P .01). Mean WOSI score was 88 for B-L shoulders and 79 for B shoulders (P .002). B-L shoulders also scored better on the DASH (P .002) and SSV (P .007). Patients had 11 loss of subjectively measured outward rotation with the arm at the side after B-L repair compared with 19 after Bankart (P .012). The original Bankart, with tunnels through the glenoid rim, had less redislocation(s) or subluxation(s) than shoulders done with anchors (P .048). Conclusions: Results were better after the Bristow-Latarjet repair than after Bankart repairs done with anchors with respect to postoperative stability and subjective evaluation. Shoulders with original Bankart repair also seemed to be more stable than shoulders repaired with anchors. Level of evidence: Level III, Retrospective Case Control Study, Treatment Study. 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Keywords: Bankart; Bristow-Latarjet; shoulder repair; recurrent instability; anterior instability

The study was approved by EPN (Regional Ethical Review Board), Ume a, Sweden, 13 May 2009 (09-047M). *Reprint requests: Lennart Hovelius, MD, PhD, Furumovgen 26 A, a 80642, Gvle, Sweden. a E-mail address: hovelius@swipnet.se (L. Hovelius).

The Bankart procedure, as performed by Rowe et al,23 is considered to be the best procedure to stabilize recurrent anterior shoulder dislocation.2 The rate of redislocations in their study23 was 3%, and in 2 previous reports on the

1058-2746/$ - see front matter 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2011.02.005

2 Bankart repair done with bony tunnels through the glenoid rim, we were able to reproduce the results.11,14 The Bristow repair was named by Helfet,8 who described how Bristow transferred the tip of the coracoid process through the subscapularis muscle on the joint capsule without any screw attachment. Latarjet described a modied method using 1 screw (and others 2) that xated the coracoid in a lying position at on the glenoid neck.17,21,27 The potential benets with this repair are better stability and less restriction of mobility. Although the Bristow-Latarjet repair has been criticized,29,30 good results have been reported with the May modication of the repair done with the transplant in a standing position and 1 screw.3,6,11,13,19,24,28 Most articles describing the results of different repairs for recurrent anterior dislocations have a short follow-up time.4,6,26 Furthermore, the introduction of anchors to stabilize the labrum-capsular structures to the glenoid rim seems to have lowered the efciency of the Bankart repair, with an increased recurrence rate and need of further revisions.18,26 Because these 2 techniques probably are the most common open methods to stabilize recurrent anterior shoulder instability, we think it is of interest to make a comparison of the 2 repairs in a long-term perspective. This retrospective study analyses the patients self-reported results after a minimum of 13 years for 2 series of shoulder repairs performed in 2 Swedish hospitals, 1 using BristowLatarjet 8,9,11,12,19 and the other using the Bankart repair.

L. Hovelius et al.
Table I Demographic data for 97 Bristow-Latarjet repairs and 88 Bankart repairs in the present study Variable Age at surgery, years Mean (range) Median Male/female (n) Age at primary dislocation, years Mean Median Etiology, No. Trafc accident Fall (unspecied) Downhill Contact sports Sports/other Other Failed repairs, No. No Yes Bristow-Latarjet 27.8 (17-51) 25.0 82/15 Bankart 27.4 (16-46) 25.0 68/20

22,7 21.0 4 11 11 31 23 17 92 5

21.8 20.0 8 12 12 24 15 15 81 7

Materials and methods


This study retrospectively analyzed 2 series (Table I) of patients from 2 hospitals in Sweden who underwent operations for traumatic anterior shoulder instability. The open Bankart repair was used at Vster Hospital and the Bristow-Latarjet repair at Gvle a as a Hospital. Indications for surgery were the same at the 2 hospitals. Shoulders with multidirectional instability were excluded. When capsular redundancy was diagnosed preoperatively or perioperatively, this was also addressed during surgery in the same way at both hospitals. Because this study was retrospective, preoperative data with respect to glenoid and humeral bone loss obtained from the medical records were not reliable. Between 1988 and 1995, we performed 105 Bristow-Latarjet repairs at the Orthopaedic Department at Gvle Hospital. Of these, a 8 patients died, and 97 shoulders remained for follow-up that was nished in 2009. The coracoid transfer was done via a horizontal incision in the subscapularis muscle and joint capsule. The osteotomized process (1 cm) was attached with 1 screw through the tip, in the standing position, to the prepared scapular neck. The aim at surgery was to obtain a position 1- to 3 mm medial to the glenoid rim on or below the equator. The joint capsule was anatomically closed lateral to the transferred coracoid in 56 shoulders, and an additional modied shift, duplicating the capsule, was done in 38 shoulders. The transfer in 3 shoulders was done without opening the joint after excision of capsular or periosteal tissue, before xation of the coracoid. An additional Bankart repair was done in 5 shoulders.

Postoperative complications occurred in 4 patients in the Bristow-Latarjet (B-L) group. These included, in 1 patient each, infection symptoms that resolved on antibiotics, an infection that needed antibiotics and drainage, a hematoma that resolved spontaneously, and a reoperation with tightening of the screw because the transplant was not at against the scapular neck. A study on the Bankart (B) repair was initiated in 1988 at the Orthopaedic Department of Vster Hospital. Until 1995, 93 a as repairs had been performed. The follow-up of these patients was completed during 2009. Because 5 patients had died, 88 shoulders remained for follow-up. Initially (1988-1990), bony tunnels were used for xation of the Bankart injury (10 shoulders,) but different numbers of anchors (range, 2-5) were used in 72 shoulders. Of these, 43 (60%) were repaired with 3 anchors. In 6 shoulders without a Bankart injury, imbrication of the capsule was performed as described by Rowe et al.23 The lateral part of the capsule was attached to the glenoid rim and the medial part was double-breasted. A capsular shift according to Neer et20 was added to the repair in 5 shoulders, and capsular tightening at the glenoid rim was done in further 9 shoulders. The results at the 5-year follow-up on a part of this series was published earlier.22 In the B group, there was one serious complication with infection that needed several reoperations with removal of anchors, inlay of gentamycin-loaded beads. This shoulder was permanently injured, with decreased range of motion. The number of postoperative complications (1 of 88) in the B group was similar to the B-L group (4 of 97, P .216). The follow-up was done in the same manner by letter or telephone for both series. If the patients did not answer the rst letter within 2 to 3 months, a second reminding letter was sent. If this was unanswered, the patients were contacted by telephone. At follow-up, all patients received a questionnaire with 23 different questions about their shoulder. The patients were furthermore requested to complete the Disability of Arm, Shoulder and Hand (DASH)1,15 and Western Ontario Shoulder

Comparison of Bristow-Latarjet and Bankart stabilization


Table II Differences between the 3 kinds of Bankart repair with respect to scoring, recurrence, and revision surgery Capsular imbrication (n 6) Original Bankart (n 10) Anchors (n 72) P

Follow-up time, mean years WOSI, mean DASH, mean SSV, mean SASF, mean Revision surgery (recurrence of instability) Redislocations 2 Subluxations 1 2 Revision surgery due to arthropathy

18.8 77.2 14.5 69.8 74.4 0 1 0 1 0

19.9 82.8 11.3 83.6 87.8 0 0 0 0 1

16 78.5 8.7 74.5 76.7 5 2 3 12 0

.837 .537 .502 .0443

DASH, Disabilities of Hand, Shoulder and Elbow; SASF, Subjective Assessment of Shoulder Function; SSV, Subjective Shoulder Value; WOSI, Western Ontario Shoulder Instability Index.

Instability Index (WOSI) questionnaires.16 Finally, they rated their shoulder according to the Subjective Shoulder Value (SSV)7 and the Subjective Assessment of Shoulder Function (SASF) in daily living. This rating was performed similar to the SSV, except the operated-on shoulder was compared with a normal, healthy shoulder with question, How does your shoulder function in daily living and different physical activities? Shoulder movement was assessed and marked by the patient on a formula, with gures describing exion and outward rotation for both shoulders similar to the method described by Carter et al.5 Internal rotation in extension was documented from a questionnaire where the patient described range of motion for both sides. Reduction of mobility was measured in comparison with the healthy shoulder and was not related to the preoperative values for the operated-on shoulder. No measurements were done between shoulders where bilateral surgery had been performed. We used the answers with respect to stability, strength, and shoulder movement to do a scoring according to Rowe et al.23 One patient in the B-L series had required a revision because of recurrent instability, and 5 patients in the B series underwent reoperations because of instability. One patient underwent arthroplasty because of arthropathy. These 7 patients were not followed-up. Of the 96 patients in the B-L series, 73 (76%) answered the rst letter, and 13 (14%) answered the second letter. Corresponding gures for the 82 patients in the B series were 56 (68%) and 5 (6%). Six B-L patients and 8 B patients answered the questionnaires after a telephone reminder. Further, 4 B-L patients just answered by phone compared with 11 in the B group. Two B patients did not answer the questionnaire, only the question of whether the shoulder instability had recurred. One refused to answer, and another alcoholic patient gave clearly unreliable answers.The B-L patients were more prone to participate (92 of 96) compared with B patients (69 of 82; P .008). Mean follow-up time was 17 years (range, 13-22 years) for the B-L series and 17 years (range, 13.5-20.5) for the B shoulders.

the Fisher exact test. We used 1-way analysis of variance or the Student t test for demonstrating differences in means of continuous variables. A value of P < .05 was considered signicant.

Results
Bankart operative technique
Table II summarizes the differences between the 3 groups of capsular repairs performed in the B series. The trend was that the original Bankart repairs23 had better values; however, these were not signicant (P .443 to P .837) with respect to WOSI, SSV, and SASF- scores. All repairs for recurrent instability (revisions) were performed in the group with anchors, and the revision because of arthropathy was performed among the 10 patients with the original Bankart repair with drilled tunnels through the glenoid rim. There was also a trend against better postoperative stability in the original B group, although it consisted of only 9 shoulders, 5 revisions of 72 shoulders in the anchor group compared with 0 of 9 in the original B group (P .54). When we compared the total number of revisions for recurrence, redislocations, and subluxations, the original Bankart repair2,23 seemed to be better, at 0 of 9 vs 22 of 72 (P .048).

Stability in both series


Table III reports the shoulders with revision surgery because of recurring instability, number of recurrences and/ or subluxations, and the subjective evaluation of stability for both series. Table III also includes our earlier published results for 26 Bankart repairs done according to the original technique, with mean follow-up 17.5 years.11 Of the 87 repairs (after excluding the patient with arthroplasty) in the B-group, 5 required revision because of recurrence of instability after the index operation compared with

Statistics
We used the c2 test to evaluate differences in proportions among various groups. If any cell contained 5 or fewer shoulders, we used

L. Hovelius et al.
Table III Results with respect to patients satisfaction, postoperative redislocations/subluxations and other parameters for the two operative repairs) Variables Redislocations Surgery/once/2 Subluxations Once/2 Posterior/healed Recovery Yes/almost/no P Patient satisfaction Very satised/satised Not completely satised/dissatised P Pain by movement Never/sometimes/daily P Ache Never/sometimes/daily P Disorders by activites of daily living No/some/always P The same repair again Yes/dont know/no P Throwing ability Yes/not completely/no P Do you avoid any shoulder movement because of fear of dislocation? Yes/no P Sports activity after surgery Unchanged/lower activity/quit because of shoulder P Loss of external rotation (P .012) Subjective range of shoulder motion Good/decreased/very decreased P
)

Bristow-Latarjet (n 96) 1/2/2 1/5 1/1 64/27/5

Bankart (n 80) 5/0/3 3/13 0/1 49/20/10 .14 51/20 5/4 .013 39/35/6 .036 40/34/6 .09 50/27/3 .249 63/9/8 .009 14/15/13 .579 41/39 .005 34/24/13 .328 18 43/28/9 .013

Bankarty (n 25) 1/0/0 0/0 0/3 23/1/1

75/19 1/1

17/7 0/1

52/42/1

20/3/2

64/29/2

71/23/1

24/0/1

83/12/1

24/0/1

9/19/8

1/6/4

28/68

0/25

60/11/8 11 62/32/2

16/1/2 15

Patients with revision surgery because of recurrence of instability and arthropathy excluded. Two patients in the Bankart group never answered these questions. y The results of an earlier published study on the Bankart procedure done with the original technique with bony tunnels through the glenoid rim are also shown.11

1 in 97 in the B-L group (P .08). If all incidents of instability events (revisions, recurrences, and/or subluxations) were compared, the B-L shoulders showed a signicantly lower incidence than the B-group, 13 of 97 and 25 of 87, respectively (P .017). If we compared the B shoulders with just anchor repairs, 5 revisions of 72 was signicantly more than 1 of 97 (P .049). This difference disappeared if we excluded shoulders with failed repairs prior to the index operation, which was 3 of 65 in the B group compared with 1 of 92 in the B-L group (P .18).

In the B-L series, 28 of 96 answered that they avoided some shoulder movement because they were afraid of a shoulder dislocation compared with 41 of 80 in the B group (P .005).

Subjective evaluation
Table III reports the answers regarding different subjective parameters. The B-L shoulders reported signicantly better results than the B repairs with respect to patients

Comparison of Bristow-Latarjet and Bankart stabilization satisfaction (P .013), pain by movement (P .036), and the same repair done again (P .009). The patients description of loss of outward rotation revealed that the B-L patients had lost signicantly less than the B shoulders, a mean 11.3 vs 18.5 , respectively (P .012). For all other questions, there were no signicant differences between the 2 series. Table IV reports the results of scores on 4 different assessments. The B-L shoulders scored better than the B shoulders in all assessments (P .016 to P .002).
Table IV Assessment WOSI Mean Median DASH Mean Median SSV Mean Median SASF Mean Median Rowe (1978) Mean Median Results with respect to 5 different scores Bristow-Latarjet 87.8 93.0 4.3 1 84.2 87.0 86.1 91 87.5 95 Bankart 79.0 86.8 9.5 3.3 75.3 82 77.9 87 79.9 87.5 P .002

.002

.007

Sex
In all scorings (Table V), there was a trend that female shoulders scored worse. The difference, however, was signicant only for the DASH score (P .009). Considering revisions because of recurrence of instability and recurrences or subluxations, there were no statistical differences between men and women (P .807).

.016

.009

DASH, Disabilities of Hand, Shoulder and Elbow; SASF, Subjective Assessment of Shoulder Function; SSV, Subjective Shoulder Value; WOSI, Western Ontario Shoulder Instability Index.

Disability and subluxations


At follow-up, 18 patients reported 2 subluxations: 5 of 96 in the B-L series and 13 of 18 in the B series (P .015). Table VI summarizes the mean scoring values for the B and B-L shoulders with 2 subluxations and the scoring for the remaining shoulders when these with several subluxations were excluded. The difference between the B and B-L shoulders was not signicant (P .35 to P .671). However, the difference between all shoulders with 2 subluxations and the others (when recurrent subluxations excluded) was highly signicant (P < .001) when scored according to WOSI, DASH, SSV, and SASF.
Table V Recurrences and subluxations and subjective evaluation for men and women Assessment WOSI DASH SSV SASF Redislocations Surgery 1 redislocation 2 redislocation Subluxations Men (n 150) 84.7 5.4 80.8 83.6 Women (n 35) P .289 .009 .172 .554

80.7 11.4 78.3 77.7 1 0 1 4

Failed surgery before the index operation


In the B group, 6 shoulders had 1 operation and 1 shoulder had 2 repairs that failed before the index operation. In the B-L group, 3 shoulders required 1 operation and 2 patients underwent 2 operations that failed before the index operation. Operations for remaining instability were required in 2 of 7 B shoulders compared with 0 of 5 in the B-L group (P .318). The patients with shoulders with no further surgery were very satised, 4 of 5 in the B-L group and 4 of 5 in the B group. One B-L patient was dissatised and 1 B patient was not completely satised. At follow-up, 2 of 5 of the B-L shoulders reported 2 subluxations compared with 1 with redislocation (2) and 1 with subluxations (2) in the B group (P .5).

5 2 4 21

DASH, Disabilities of Hand, Shoulder and Elbow; SASF, Subjective Assessment of Shoulder Function; SSV, Subjective Shoulder Value; WOSI, Western Ontario Shoulder Instability Index.

patients in the B-L series. In the B series, as mentioned, 5 shoulders had revision surgeries because of recurrence of the instability, and 1 shoulder had an arthroplasty because of arthropathy. Further, 3 shoulders in the B series had arthroscopies because of pain or insufcient range of motion, or both.

Discussion
We have previously compared the original Bankart repair, which was done with bone tunnels through the glenoid,2,23 with the Putti-Platt procedure14 and with the BristowLatarjet repair.11 In the rst study, the follow-up was rather short, and the results were signicantly better for the Bankart repairs than for the Putti-Platt procedures.14 In

Surgery during follow-up


In the B-L series, as mentioned, 1 shoulder required revision surgery because of recurrence of instability. Different screw problems required screw removal in a further 3

6
Table VI Assessment WOSI DASH SSV SASF Scoring for shoulders with 2 subluxations and for all other shoulders when these were excluded P Bristow-Latarjet (n 4) 54.5 Bankart (n 11) 60.0 Total (n 15) 59.2

L. Hovelius et al.

Total (Sublux excluded) 86.6 5.0 83.3 86.0

.671) .001y .649) <.001y .411) <.001y .35) <.001y

25.3 40.0 40.3

19.3 55.8 53.2

21.0 51.6 49.7

DASH, Disabilities of Hand, Shoulder and Elbow; SASF, Subjective Assessment of Shoulder Function; SSV, Subjective Shoulder Value; WOSI, Western Ontario Shoulder Instability Index. ) When comparing the Bristow-Latarjet and Bankart shoulders. y When comparing the shoulders with or without 2 subluxations.

the second study, we had 15 years of follow-up and the results were the same for the Bankart and Bristow-Latarjet repairs.11 These ndings were also in accordance with the results presented by Weaver and Derkash,28 who compared the original Bankart2,23 with the Bristow-Latarjet repair. The present study shows better results for the BristowLatarjet shoulders with respect to subjective postoperative range of motion, stability, and subjective scorings. One of 10 patients in whom the Bankart repairs were done with drill holes through the glenoid rim had an arthroplasty because of arthropathy; however, the remaining 9 shoulders with the original Bankart technique23 seemed to be better with respect to stability (P .048) than those with anchors (Table II). These original Bankart repairs did not differ from the Bristow-Latarjet repairs with respect to postoperative stability, WOSI, SSV, or SASF scores (Tables II and III). The original technique with bone tunnels seems to be better than the anchor technique that we used in this series. Possibly the Bankart lesion in this study was better xed to the glenoid with the old drill hole technique. These ndings are in agreement with the study by Tamai et al,25 although their study, as ours, has limitations. Another reason for the better results in the shoulders with drill holes may be that the anchors were placed too medial and not at the bone/ cartilage edge of the glenoid. In an ongoing study analyzing technical aspects of the Bristow-Latarjet repair, stability repairs had failed in 23 of 318 repairs before the Bristow-Latarjet operation and none has required further surgery.9 In the present study, 2 of 7 shoulders where the Bankart repair was a revision procedure needed further stabilizing surgery (P .048). This should mean that the Bristow-Latarjet procedure is better than the Bankart repair (with anchors) when doing surgery after earlier failures. In this study, we have followed up the patients for a rather long timeda mean of 17 years (range, 13-22 years)dwhich is still shorter than Schroder et al,24 who presented a 26-year outcome study of 52 shoulders. They had 15% recurrences

and subluxations, and 70% of the shoulders were considered excellent or good. Considering that their patients were younger than ours (aged 18-22 years), our results after the Bristow repair seem to be rather similar. If we exclude the 7 shoulders with failed surgery before the Bankart repair, only 3 of 65 repairs (5%) made with anchors required further stabilizing surgery. These gures are similar or slightly better, especially when considering our long follow-up time, than presented in other reports using the anchor technique. Ungerbck et al26 had 7% o revisions (3 of 42) after a mean follow-up of 47 months. Magnusson et al18 reported a revision rate of 6% (3 of 47) after 69 months. They pointed out the importance of an extended follow-up. In our opinion, all reports dealing with results after shoulder stabilizations should have a minimum follow-up of 5 years because we found a signicant worsening between 2 and 5 years.9 Most patients were satised at follow-up, especially in the B-L group (P .013; Table III). Remaining symptoms, pain by daily living, and ache and pain at motion were not uncommon, perhaps due to arthropathy, which increases with time.10 Subluxation is subjective and is not possible to verify objectively; however, as in our ongoing study on the Bristow repairs,9 repeated occasions with subluxations (2) lower shoulder function (Table VI). Our observation that women score worse (Table V), although they had similar rate of recurrences, is the same as we found 25 years after the primary dislocation10 and may possibly be explained by the general higher musculoskeletal morbidity in women. The retrospective design with this study is a limitation because inclusion and exclusion criteria are difcult to dene. If the indications for surgery differ between the hospitals, we cannot exclude bias. Also, questionnaire assessments may be questionable, especially with respect to range of motion. However, subjective measurements of shoulder motion have been considered as fairly appropriate by others.5 A follow-up at the hospital with physical and radiographic examination was not possible in this study

Comparison of Bristow-Latarjet and Bankart stabilization because our patients were spread internationally. Moreover, it is notable that there were only 9 shoulders in the B group with drill holes. Because the anchor technique was new at that time, it is probable that technical errors may play a role. Finally, it is unclear why the B-L patients were more willing to participate in the follow-up, which possibly caused a bias. Yet, the strength of this study is the complete (no dropouts) 17-year follow-up and also that the 2 consecutive groups had a similar demography (Table I) and were operated on in similar settings.

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Bristow-Laterjet procedure (Study III). Long-term follow-up in 319 shoulders. J Shoulder Elbow Surg [in press]; doi: 10.1016/j.jse.2011. 03.020 Hovelius L, Saeb M. Neer Award 2008. Arthropathy after primary o anterior shoulder dislocation, 223 shoulders prospectively followed for 25 years. J Shoulder Elbow Surg 2009;18:339-47. doi:10.1016/j.jse. 2008.11.004 Hovelius L, Sandstrm B, Rsmark D, Saeb M, Sundgren K, o o o Malmqvist B. Long-term results with the Bankart and Bristow-Latarjet procedures. Recurrent shoulder instability and arthropathy. J Shoulder Elbow Surg 2001;10:445-52. Hovelius L, Sandstrm B, Saeb M. One hundred eighteen Bristowo o Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for 15 years: study IIethe evolution of dislocation arthropathy. J Shoulder Elbow Surg 2006;15:279-89. doi:10. 1016/j.jse.2005.09.014 Hovelius L, Sandstrm B, Sundgren K, Saeb M. One hundred eighteen o o Bristow-Latarjet repairs for recurrent anterior dislocation of the shoulder prospectively followed for 15 years. Study I: Clinical Results. J Shoulder Elbow Surg 2004;13:509-16. doi:10.1016/j.jse.2004.02.013 Hovelius L, Thorling J, Fredin H. Recurrent anterior dislocation of the shoulder. Results after the Bankart and Putti-Platt operations. J Bone Joint Surg Am 1979;61:566-9. Hudak PL, Amdi PC, Bombardier C. Development of an Upper extremity outcome measure: The DASH (disabilities of the arm, shoulder and hand). Am J Ind Med 1996;29:602-8. Kirkley A, Grifn S, McLintock H, Ng L. The development and evaluation of a disease-specic quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med 1998;26:764-72.  Latarjet M. A propos du traitment des luxations rcidivantes de e lpaule. Lyon Chir 1954;49:994-7. e Magnusson L, Kartus J, Ejerhed L, Hultenheim I, Sernert N, Karlsson J. Revisiting the open Bankart experience. A four- to nineyear follow-up. Am J Sports Med 2002;30:778-82. doi:10.1016/ S0749-8063(3)00440-7 May V. A modied Bristow operation for anterior recurrent dislocation of the shoulder. J Bone Joint Surg Am 1970;52:1010-6. Neer CS, Foster C. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am 1980;62:897-908. Patte D, Bernageau J, Rodineau J, Gardes JC. Unstable painful shoulders. Rev Chir Orthop 1980;66:157-65. Rahme H, Vikerfors O, Ludvigsson L, Elvn M, Michaelsson K. Loss e of external rotation after open Bankart repair: an important prognostic factor for patient satisfaction. Knee Surg Sports Traumatol Arthroscop 2010;18:404-8. doi:10.1007/s00167-009-0897-6 Rowe C, Patel D, Southmayd WW. The Bankart procedure. A long term end-result study. J Bone Joint Surg Am 1978;65:1-16. Schroder D, Provencher M, Mologne T, Muldoon M, Cox J. The modied Bristow procedure for anterior shoulder instability. 26-year outcomes in naval academy midshipmen. Am J Sports Med 2006:77886. doi:10.1177/0363546505282618 Tamai K, Higashi A, Tanabe T, Hamada J. Recurrences after open Bankart repair. A potential risk with use of suture anchors. J Shoulder Elbow Surg 1999;8:37-41. Ungersbck A, Michel M, Hertel R. Factors inuencing the results of o a modied Bankart procedure. J Shoulder Elbow Surg 1995;4:365-9. Walch G. Chronic anterior glenohumeral instability. Instructional course lecture. J Bone Joint Surg Br 1995;78:670-7. Weaver J, Derkash R. Dont forget the Bristow-Latarjet procedure. Clin Orthop 1994;308:102-10. Young C, Rockwood C. Complications of a failed Bristow procedure and their management. J Bone Joint Surg Am 1991;73:969-81. Zuckerman JD, Matsen F. Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg Am 1984;6: 175-80.

10.

11.

12.

Conclusion
13.

This long-term follow-up showed that the BristowLatarjet procedure had better subjective scores and stability than the open Bankart repair done with suture anchors. The results for the Bankart repairs seemed to be better when the original drill-hole technique was used.

14.

15.

Disclaimer
The authors, their immediate families, and any research foundations with which they are afliated have not received any nancial payments or other benets from any commercial entity related to the subject of this article.

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17. 18.

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