Original Article With Video Illustration Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repairs: Significance of the Inverted-Pear Glenoid and the Humeral Engaging Hill-Sachs Lesion Stephen S. Burkhart, M.D., and Joe F. De Beer, M.D. Purpose: Our goal was to analyze the results of 194 consecutive arthroscopic Bankart repairs (performed by 2 surgeons with an identical suture anchor technique) in order to identify specific factors related to recurrence of instability. Type of Study: Case series. Materials and Methods: We analyzed 194 consecutive arthroscopic Bankart repairs by suture anchor technique performed for traumatic anterior-inferior instability. The average follow-up was 27 months (range, 14 to 79 months). There were 101 contact athletes (96 South African rugby players and 5 American football players). We identified significant bone defects on either the humerus or the glenoid as (1) “inverted-pear” glenoid, in which the normally pear-shaped glenoid had lost enough anterior-inferior bone to assume the shape of an inverted pear; or (2) “engaging” Hill-Sachs lesion of the humerus, in which the orientation of the Hill-Sachs lesion was such that it engaged the anterior glenoid with the shoulder in abduction and external rotation. Results: There were 21 recurrent dislocations and subluxations (14 dislocations, 7 subluxations). Of those 21 shoulders with recurrent instability, 14 had significant bone defects (3 engaging Hill-Sachs and 11 inverted-pear Bankart lesions). For the group of patients without significant bone defects (173 shoulders), there were 7 recurrences (4% recurrence rate). For the group with significant bone defects (21 patients), there were 14 recurrences (67% recurrence rate). For contact athletes without significant bone defects, there was a 6.5% recurrence rate, whereas for contact athletes with significant bone defects, there was an 89% recurrence rate. Conclusions: (1) Arthroscopic Bankart repairs give results equal to open Bankart repairs if there are no significant structural bone deficits (engaging Hill-Sachs or inverted-pear Bankart lesions). (2) Patients with significant bone deficits as defined in this study are not candidates for arthroscopic Bankart repair. (3) Contact athletes without structural bone deficits may be treated by arthroscopic Bankart repair. However, contact athletes with bone deficiency require open surgery aimed at their specific anatomic deficiencies. (4) For patients with significant glenoid bone loss, the surgeon should consider reconstruction by means of the Latarjet procedure, using a large coracoid bone graft. Key Words: Instability—Arthroscopic instability repair—Shoulder instability—Bone defect—Bone graft—Latarjet reconstruction. T he debate over the supremacy of open versus arthroscopic surgical repair for traumatic anterior instability rages now more energetically than ever. After more than a decade of unfocused confrontation, the debate has finally crystallized into a classic con- flict between “lumpers” (the open proponents) and “splitters” (the arthroscopic proponents). On the one hand, the lumpers view every report of high recur- rence rates from outdated transglenoid repairs as evi- dence that all arthroscopic repairs are somehow inher- ently inferior to the “gold standard” open repairs. On the other hand, the arthroscopists, who have evolved From the Department of Orthopaedic Surgery, Baylor College of Medicine and the University of Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A. (S.S.B.); and the Sports Sci- ence Institute of South Africa, Oranjezicht, Capetown, South Africa (J.F.DeB.). Address correspondence and reprint requests to Stephen S. Burkhart, M.D., 540 Madison Oak Dr, Suite 620, San Antonio, TX 78258, U.S.A. © 2000 by the Arthroscopy Association of North America 0749-8063/00/1607-2511$3.00/0 doi: 10.1053/jars.2000.17715 NOTE: To access the video illustration accompanying this report, visit the October on-line issue of Arthroscopy at www. arthroscopyjournal.org 677 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 7 (October), 2000: pp 677– 694