Filling in the Gaps

The Journal of Bone and Joint Surgery—British Volume was launched in 1948 with an expression of good wishes from His Majesty King George VI, conveyed to the readership by Sir Reginald Watson-Jones. What could follow such a distinguished preface better than a symposium on the treatment of recurrent anterior dislocation of the shoulder, with contributions from some of the most notable orthopaedic surgeons of the day? The transcript of a heated interchange among the experts that accompanies the formal articles in this sequence provides an enlightening insight into the personalities and social dynamics of the era. For Mr A.S. Blundell Bankart of London, there was really no need for a discussion of the preferred treatment for anterior shoulder instability. Once one had defined the “essential anatomical defect” producing recurrent anterior shoulder instability, as Mr Bankart had done, the only reasonable treatment was quite obvious. “There is only one rational operation for this condition; it is applicable to every genuine case of anterior recurrent dislocation; it is almost foolproof; and, when it is properly done, the patient is cured—the dislocation never recurs and the patient rapidly regains full use of his arm.” Being a gentleman, Mr Bankart could be taken at his word, without the need for tedious follow-up studies. “I have no figures, but I have probably done this operation more than anyone else . . . and I have never had a case in which the dislocation has recurred nor one in which there was serious limitation of movement after it.” Described in his obituary as “a shy man . . . of courtly bearing and great charm,”24 Mr Bankart refused to attribute this remarkable record of success to any unusual surgical talent on his part. “When I say that the operation is almost foolproof, I do not mean that fools should practice surgery, but that any surgeon of ordinary competence is capable of fixing a piece of fibrous tissue to a bone when both are exposed to view and accessible, and it is difficult to see how he could fail.” Henry Osmond “Nobby” Clarke, future Knight Commander of the Victorian Order and champion of the Putti-Platt procedure, did not quail to take up the proffered gauntlet. “Mr. Bankart has made a devastating attack,” he riposted. “We looked forward to it eagerly . . . I have assisted Mr. Bankart myself and I have watched many surgeons since—distinguished, mildly distinguished, and undistinguished. I have seen every conceivable form of trauma applied to the anterior margin of the glenoid; and I have seen a surgeon, after operating for one hour, faced with total disappearance of the bone surface he has been trying to drill. For these reasons I urge the claims of an easier repair.” Although Mr Bankart’s procedure does seem to have prevailed into the 21st century, few contemporary surgeons would claim to match his unbroken string of successes or concur with his doctrinaire assertion that a bony injury to the glenoid is never—or hardly ever—associated with recurrent anterior dislocation. In 1942, Bost and Inman published an account of 10 cases of recurrent anterior dislocation that they had repaired with Bankart’s technique in the prior decade. Their principle purpose was to expand Mr Bankart’s description of the essential lesion to a triad of findings, including detachment of the glenoid labrum and anterior capsule, a defect in the posterolateral portion of the head of the humerus, and erosion or fracture of the glenoid rim. The importance of this last element of the triad, bone loss from the anterior rim of the glenoid cavity, has become the focus of intense interest in recent years. A number of studies have looked at the prevalence, location, and configuration of these defects and proposed ways to measure them, model them, and most importantly, determine whether they require direct repair or reconstruction. Described methods for detecting and quantifying these defects with preoperative imaging include special radiographic views, computed tomography (CT), and 3-dimensional CT reconstruction. The more sophisticated the technology employed, the more common the lesions seem to become. Utilizing a 3-dimensional CT reconstruction technique, Sugaya et al reported a 90% prevalence of glenoid rim lesions in a series of 100 patients, while Griffith et al used reformatted CT images to reveal glenoid “flattening” in 91% of 46 dislocated shoulders. Saito et al later emphasized that this defect usually involves the anterior glenoid rather than the anterior-inferior glenoid, as depicted in a number of laboratory models. Although glenoid rim defects may in fact be common, most surgeons have been content to ignore them unless they reach a certain magnitude. The critical size at which bony reconstruction is required has been the subject of both laboratory and clinical research. Opinions even vary on the optimal way to describe the size of the defects. Calculating the reduction in glenoid width may be the most common method, but measurement of the absolute length of the defect or the decrease in glenoid surface area have also been used. In 1998, Bigliani et al reported on 25 shoulders with glenoid defects garnered from 200 operations for recurrent anterior or anteroinferior shoulder instability. These authors created an often-quoted classification system that recognized that glenoid bone loss might present with an ununited bony fragment, a malunited fragment, or a frank defect of variable size. “The majority of recurrent anterior dislocations,” they opined, “can be treated by suturing the fracture fragment or capsule or both to the glenoid rim and addressing capsular laxity.” They postulated that fragments DOI = 10.177/0363546503262911