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Arthroscopic stabilization for traumatic anterior dislocation of the shoulder: suture anchor fixation versus transglenoid technique
J Orthop Sci (2008) 13:318–323 DOI 10.1007/s00776-008-1239-1
Original article Arthroscopic stabilization for traumatic anterior dislocation of the shoulder: suture anchor fixation versus transglenoid technique JUNG-MAN KIM, YANG-SOO KIM, KEE-YONG HA, and HYUN-MIN CHO Department of Orthopaedic Surgery, Kangnam St. Mary’s Hospital, Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul 137-701, Korea
Abstract Background. The purpose of this study was to evaluate and compare the clinical results of arthroscopic capsulolabral reconstruction using arthroscopic transglenoid fixation and a suture anchor fixation for anterior dislocation of the shoulder. Methods. From December 1999 to September 2006, 46 patients who underwent arthroscopic capsulolabral reconstruction for their anterior dislocation of the shoulder were enrolled, and their surgical outcomes were retrospectively evaluated. In group A (26 patients), the procedure was performed with Caspari’s transglenoid technique. In group B (20 patients), the capsulolabral reconstruction was done using the suture anchor method. The postoperative assessment including American Shoulder and Elbow Surgeons’ (ASES) scores, recurrent instability, the level of return to previous sports activity, and satisfaction with the treatment were compared between the two groups. Statistical analysis was performed using Student’s t-test, chi-squared analysis, and a Pearson correlation coefficient. Results. There were significant differences in ASES scores (group A 76.8 vs. group B 85.5), satisfaction with the surgery (group A 6.5 vs. group B 8.2 — out of 10) and in the level of return to previous sports activity (group A 7.2 vs. group B 8.3 — out of 10) at last follow-up. Recurrent instability occurred in 7 patients in group A (26.9%) and in two cases in group B (10.0%). Conclusions. The arthroscopic capsulolabral reconstruction using a suture anchor was a more reliable treatment option (in regard to satisfaction, functional recovery, and recurrent instability) than the transglenoid fixation technique for anterior dislocation of the shoulder.
Introduction Since Bankart1 first described the lesion observed in patients with recurrent shoulder dislocations, avulsion Offprint requests to: Y.-S. Kim Received: August 2, 2007 / Accepted: March 31, 2008
of the anterior capsulolabral complex from the anterior glenoid has become known to be the main pathology with anterior dislocation of the shoulder. The treatment of anterior dislocation is focused mainly on a Bankart repair with additional tensioning of the inferior glenohumeral ligament, even though the pathological features of this injury include a Bankart lesion, a Hill-Sachs lesion, tear of the inferior glenohumeral ligament, a glenoid fracture, and a rotator cuff tear.2,3 Various techniques have been proposed to repair a Bankart lesion, including an open Bankart repair by drill hole,1 metal staples,4 capsular shift,5 arthroscopic Bankart repair with transglenoid fixation,6 and suture anchoring systems. Even though the open Bankart repair has been considered the gold standard of treatment, recent reports have indicated that arthroscopic repair and reconstruction of the anterior capsulolabral complex provides similar and sometimes superior results with respect to postoperative range of motion compared with the open technique.5,7–9 There are two techniques for an arthroscopic Bankart repair: the transglenoid fixation technique and the anchor fixation technique. Since Caspari6 reported satisfactory results in 96% of 49 patients treated with a transglenoid technique, many authors10–12 have reported various results with the transglenoid fixation techniques. In a meta-analysis of the transglenoid fixation technique, Kandziora et al.13 reported 73.6% (42%–91.3%) of excellent/good results in the Rowe score and an average rate of recurrence of 21.8% (8.7%–49%). Recently, it has been reported that the arthroscopic Bankart repair with suture anchors provides superior stability compared to previous techniques.9,13–15 In a biomechanical study with fresh cadavers, Okamura et al.16 demonstrated that the effective labral depth after an arthroscopic Bankart repair with the suture anchor method was significantly greater than that with the transglenoid methods. In contrast to previous reports, however, Koss et al.15 reported 30% recurrent anterior
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instability in patients treated with a suture anchor fixation technique. In a retrospective study to compare the recurrence rates following transglenoid labrum fixation and fixation using the suture anchor technique, Kandziora et al.13 reported that there was no significant correlation between the redislocation rates and the type of surgery. These two techniques are similar in regard to reattachment of the anterior labrum and glenohumeral ligament complex. However, Caspari’s transglenoid technique mainly focuses on suturing the glenohumeral ligament.6 On the other hand, with the anchor technique, the detached anterior labrum is also repaired with the ligament.17 Few reports have compared the two arthroscopic techniques.16,18 The purpose of this study was to compare the clinical results of the transglenoid fixation method and the suture anchor method for treating anterior dislocation of shoulder.
rior working portal, anteroinferior working portal) were established, all internal structures of the involved glenohumeral joint were inspected. In group A, the Caspari’s transglenoid technique was performed with No. 2 ethibond suture (0.9 mm thick); and in group B, suture anchor technique was used with FASTak anchor (Arthrex, Naples, FL, USA). The patient groups was divided chronologically: Caspari’s transglenoid technique (group A) was used between 1999 and 2001, and the suture anchor technique (group B) was used between 2001 and 2006.
Materials and methods From December 1999 to September 2006, a total of 65 patients underwent arthroscopic capsulolabral reconstruction for anterior dislocation of the shoulder at our hospital. Among them, 12 patients were lost to followup; and 46 shoulders in 46 consecutive patients who met the following criteria were included in this study. The patients were divided into two groups according to the operation: the transglenoid fixation technique (group A, 26 patients) and the suture anchor method (group B, 20 patients). All surgical procedures were performed after obtaining informed consent from patients. The average follow-up period was 48.9 months (range 24–95 months). Patients were selected on the basis of the following inclusion criteria: (1) anterior instability as a result of one or more traumatic dislocations that were considered traumatic based on the patient’s history and the necessity of reducing the joint by a physician; (2) subjective symptoms of shoulder instability and a positive apprehension test; (3) arthroscopically confirmed Bankart lesion or capsular laxity. Patients were excluded on the basis of the following criteria: (1) previous operation on the same shoulder; (2) clinical evidence of multidirectional instability or posterior instability. Surgical procedures The arthroscopic stabilization of all patients was performed by one senior author (J.M. Kim). The patients were positioned in the lateral decubitus position for the operation, and while under general anesthesia 5-kg traction force was applied to the operated arm. After three portals (standard posterior viewing portal, anterosupe-
Postoperative management At 2–4 weeks after the operation the patients were allowed to remove the sling intermittently for exercise and start a passive exercise program that included forward flexion to 60°, abduction to 60°, and pendulum exercises. After 4 weeks, all patients began isometric exercises for the deltoid muscle and external rotator as well as active assisted motion exercises with avoidance of external rotation until 8 weeks after surgery. Active motion of all directional and strengthening exercises began at 8 weeks postoperatively. The return to sports activity was permitted 6 months after surgery. Data acquisition We collected the following data retrospectively from the clinical notes: preoperative and postoperative range of motion (ROM) of the shoulder (forward flexion, external rotation at the side, external rotation at 90° abduction, internal rotation) using an universal goniometer in the supine position; age and sex of the patients at the time of surgery; number of dislocations before surgery; chief complaint; cause of dislocation; duration of symptoms before surgery; and early postoperative complications. The operative record was reviewed to evaluate the type of labral lesion, the existence of a Hill-Sachs lesion, concomitant lesions, the number and location of sutures placed in the capsule, and the number and location of suture anchors used for the repair. Determination of the labral lesion type was based on the classification of Adolfsson and Lysholm.19 We obtained the preoperative and postoperative radiographs of the shoulder. Preoperatively, we examined all of the patients with magnetic resonance imaging (MRI) to detect the presence of a Bankart lesion. An attempt was made to contact all 65 patients by telephone or e-mail. Among them, 32 patients who lived locally returned for physical and radiographic examinations. The outcomes of the two procedures were determined based on the following variables: duration until the return to full ROM, recurrence of subjective or
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objective symptoms of instability, satisfaction with the procedure, questionnaire results of the American Shoulder and Elbow Surgeons’ (ASES) scoring system,20 return to previous level of sports activity, and complications. We scored the return level to previous sports activity and the satisfaction with the treatment by a Visual Analogue Scale (VAS) scoring system; complete recovery to the preoperative sports level was scored as 10, and complete loss of any sports activity was regarded as 0; in the same manner, complete satisfaction with the treatment was scored as 10, and total dissatisfaction was scored as 0.
The interval from the first dislocation to surgery was <1 year in 11 patients, 1–2 years in 7 patients, and >2 years in 28 patients (range 1 month to 30 years in the two groups).
Statistical analysis Statistical analysis was performed using Student’s t-test and chi-squared analysis, with P < 0.05 considered a significant difference. SPSS version 10.0 software (SPSS, Chicago, IL, USA) supported the statistical evaluation. Pearson’s correlation coefficients were used to detect the variables that correlated with the rate of postoperative recurrent instability symptoms.
Results Characteristics of patients The demographics of the two groups are summarized in Table 1. The variables were not significantly different from each other for the two groups (P > 0.05). Altogether, 46 were included in this study: 43 (93.5%) patients were male, and 3 (6.5%) were female. The average age of the patients was 25.5 years at the time of surgery. All patients had a history of symptomatic anterior dislocation with a positive anterior apprehension test. The average duration of symptoms of instability was 48.7 months before surgery (P > 0.05). The average number of dislocations before surgery was 11.9 (P > 0.05). In the two groups, 16 patients had a history of less than 5 dislocations, 9 patients reported 5–10 dislocations, and 21 patients reported >10 dislocations.
Range of motion Surgical results are summarized in Table 2. Postoperative ROM of the shoulder was fully recovered in most of the patients. The average duration for complete recovery of ROM after surgery was 5.4 months (P > 0.05). However, three patients (6.5%) — two patients in the transglenoid group one patient in the suture anchor group — demonstrated a mean loss of external rotation of 15.3° at the side (range 17.5°–9.3°) and 9.2° in the abduction position (range 12.2°–5.5°) compared with the opposite shoulder at the last follow-up. Postoperative function The ASES scores of the suture anchor group (average 85.5, range 69–99) were significantly higher than those of the transglenoid group (average 76.8, range 40–99) at the time of the last follow-up (P < .05) (Table 2). The average satisfactory score for the treatment was 6.5 (range 2.5–9.0) in the transglenoid group and 8.2 (range 6–10) in the suture anchor group (P < 0.05). The average score for return to the previous level of sports activity was significantly higher in the suture anchor group (8.3, range 6–10) than that in the transglenoid group (7.2, range 4–9) (P < 0.05). Recurrent instability If the patients complained of instability symptoms without objective evidence of recurrent instability, we included them in the failed cases. All failed cases had a positive anterior apprehension test and positive anterior drawer signs on physical examination. Recurrent instability occurred in seven cases (26.9%) in the transglenoid group (group A) and two cases (10.0%) in the suture anchor group (group B) (Table 3). Only one
Table 1. Demographics of the patients Variables No. of patients Age at operation (years) Sex (men/women) Age at onset (years) No. of dislocations before operation Duration of symptoms before operation (months) Postoperative follow-up (months) All values are averages
Transglenoid repair (group A)
Suture anchor repair (group B)
P
26 26.7 24/2 22.0 11.4 55.9 56.4
20 24.3 19/1 20.9 12.3 41.4 41.4
0.41 0.86 0.67 0.86 0.48 0.02
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Table 2. Operative results Variables Concomitant SLAP Time to return to full ROM (months) Labral lesion A B C Hill-Sachs lesions (no. of cases) No. of sutures/fixation No. of failed cases D/L S/L Total Postoperative recurrence period (months) ASES score Satisfaction with treatment Return to sports activity level score
Transglenoid fixation (group A)
Suture anchor fixation (group B)
P
6 cases 5.6
7 cases 5.1
0.57 0.39
13 5 8 21/26 (80.8%) 5.1
9 3 8 14/20 (70.0%) 4.9
0.73 0.55
2 5 7/26 (26.9%) 20.2 76.8 6.5 7.2
0 2 2/20 (10.0%) 16 85.5 8.2 8.3
0.044
0.047 0.002 0.005
SLAP, superior labrum anterior posterior; ROM, range of motion; D/L, dislocation; S/L, subluxation; ASES, American Shoulder and Elbow Surgeons
patient, who sustained a recurrent dislocation, had undergone open surgical stabilization at our hospital. The average satisfaction score with treatment of the patients with recurrent instability was 6.1 (highest possible score is 10), and the average return level to previous sports activity was 6.9 (highest possible score is 10). There was no significant correlation (correlation coefficient ≥0.4) between the postoperative recurrence of instability and several variables, including the patient’s age at the time of surgery, age at first dislocation, concomitant superior labrum anterior and posterior (SLAP) lesion, number of dislocations before surgery, duration of symptoms before surgery, time to the return to full ROM, type of Bankart lesion, existence of a Hill-Sachs lesion, and number of fixation points and anchor screws (P < 0.05).
Discussion This study demonstrated that arthroscopic stabilization using a suture anchor was an effective surgical technique for anterior dislocation of the shoulder. We believe that the low satisfactory score in the transglenoid group was due to the high recurrence rate of the instability after surgery. These results revealed that patients who underwent surgery with the suture anchor technique were more satisfied with the results and could return to their previous level of sports activity more easily than those who underwent the transglenoid technique. Postoperative ROM of the shoulder was fully recovered in most of the patients in our series. We found that the excellent restoration of ROM was one of the advantages of the arthroscopic procedures.
Various rates of recurrent instability after arthroscopic stabilization, ranging from 4% to 60%, have been reported. 6,14,15 Walton et al.21 reported, based on a metaanalysis study, that the redislocation rates for the transglenoid technique were higher than those reported for the anchor technique (15% vs. 7%). In addition, they stressed the important roles of the capsule and labrum, which are vitally important to maintain shoulder stability. We believe that the difference in recurrence rates between the two groups resulted from two technical points. First, with Caspari’s technique, even though several sutures pass through the capsule and labrum, all the structures are fixed at only one point on the anterior glenoid; in contrast, with the suture anchor technique, every stitch of the capsule and labrum is fixed to the corresponding site on the anterior glenoid. Second, with the transglenoid fixation technique, the strands passing through the capsulolabral complex make a long tract from the anterior glenoid to the medioinferior border of the scapula in the infraspinatus fossa. In other words, the distance from the suture site of the capsulolabral structure to the fixation site on the bone is exceedingly long with the transglenoid fixation method, and this type of fixation may easily lose its holding capacity of the capsule. In previous reports, the recurrence rate for instability after surgery was correlated with patient age, number of preoperative dislocations, and the type of the labrum lesion.12,13,15 However, we could not find any significant correlation of recurrent instability with these factors. We believe that recurrence of instability after surgery depends on the technique and method of surgery, rather than other factors. There are some limitations of this study. There is a potential for bias, as the study was retrospective, with
M 21
M 18
M 18
F
M 21
M 25
M 23
3
4
5
6
7
8
9
F/U, follow-up
Average
M 20
2
21.2
24
M 21
1
Case
18.9
21
22
17
24
17
17
18
19
15 1 3 5 30 4 2 7 11
− − + − − − + − 8.1
10
−
23
12
18
5
17
57
52
20
9
17
No. of Time from Age at D/L operation to before recurrence first Sex Age D/L SLAP surgery (months)
Table 3. Summary of patients with recurrent instability
Slip down (S/L) No special event (S/L) Ski injury (D/L) Swimming (S/L) Volleyball (D/L) No special event (S/L) No special event (S/L) No special event (S/L) No special event (S/L)
Reason for recurrence
−
−
−
−
+
−
−
−
−
B
B
A
A
A
A
A
A
A
53.2
32
24
53
41
82
84
73
49
41
5.3
5
4
5
4
6
3
8
7
6
C
A
A
C
C
C
C
A
A
+
+
−
−
+
+
+
+
+
5
5
5
4
6
5
5
5
6
4
70.7
84
83
69
77
60
76
40
77.5
70
6.1
7
7
6
8
2.5
6
5
8
5
6.9
7
7
7
9
4
6
7
7.5
8
F/U period after Time to Type of HillSecond operation full ROM labral Sachs No. of ASES Sports operation Group (months) (months) lesion lesion fixations score Satisfaction level
322 J.M. Kim et al.: Arthroscopic fixation of shoulder dislocation
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no randomization when selecting the patients. The follow-up periods were different between the two groups. We recognized that this difference in the evaluation period can influence the outcome, especially the recurrence of instability. However, all recurrent instability symptoms of the failed patients in our series occurred within 20 months after surgery, except for two patients who suffered from new trauma.
6. Caspari R. Arthroscopic reconstruction for anterior shoulder instability. Oper Tech Orthop 1988;3:59–66. 7. Guanche CA, Quick DC, Sodergren KM, Buss DD. Arthroscopic versus open reconstruction of the shoulder in patients with isolated Bankart lesions. Am J Sports Med 1996;24:144–8. 8. Sperling JW, Duncan SF, Torchia ME, O’Driscoll SW, Cofield RH. Bankart repair in patients aged fifty years or greater: results of arthroscopic and open repairs. J Shoulder Elbow Surg 2005; 14:111–3. 9. Fabbriciani C, Milano G, Demontis A, Fadda S, Ziranu F, Mulas PD. Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy 2004;20: 456–62. 10. Ekelund A, Nyberg R. Arthroscopic shoulder stabilization using transglenoid sutures. Scand J Med Sci Sports 1998;8:416–20. 11. Pagnani MJ, Warren RF, Altchek DW, Wickiewicz TL, Anderson AF. Arthroscopic shoulder stabilization using transglenoid sutures: a four-year minimum follow up. Am J Sports Med 1996; 24:459–67. 12. Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S. Arthroscopic stabilization for recurrent anterior shoulder dislocation: results of 59 cases. Arthroscopy 1995;11:173–9. 13. Kandziora F, Jäger A, Bischof F, Herresthal J, Starker M, Mittlmeier T. Arthroscopic labrum refixation for post traumatic anterior shoulder instability: suture anchor versus transglenoid fixation technique. Arthroscopy 2000;16:359–66. 14. Kim SH, Ha KI, Kim SH. Bankart repair in traumatic anterior shoulder instability: open versus arthroscopic technique. Arthroscopy 2002;18:755–63. 15. Koss S, Richmond JC, Woodward JS Jr. Two- to five-year followup of arthroscopic Bankart reconstruction using a suture anchor technique. Am J Sports Med 1997;25:809–12. 16. Okamura K, Takiuchi T, Aoki M, Ishii S. Labral shape after arthroscopic Bankart repair: comparisons between the anchor and Caspari methods. Arthroscopy 2005;21:194–9. 17. Wolf EM, Wilk RM, Richmond JC. Arthroscopic Bankart repair using suture anchors. Oper Tech Orthop 1991;1:184–91. 18. Romeo AA, Cohen BS, Carreira DS. Traumatic anterior shoulder instability. Orthop Clin North Am 2001;32:399–409. 19. Adolfsson L, Lysholm J. Arthroscopy and stability testing for anterior shoulder instability. Arthroscopy 1989;5:315–20. 20. Richards RR, An KN, Bigliani LU, Friedmann RJ, Gartsman GM, Gristina AG, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994;3: 347–52. 21. Walton J, Paxinos A, Tzannes A, Callanan M, Hayes K, Murrell GA. The unstable shoulder in the adolescent athlete. Am J Sports Med 2002;30:758–67.
Conclusion Precise assessment of the pathological structure of the instability and meticulous technique when reconstructing the capsulolabral structure can produce a satisfactory outcome and reduce the rate of complications in cases of instability. Acknowledgment. This work received a JOA Travel Award at the 79th annual congress of the Japanese Orthopaedic Association, Yokohama, May 2006. There was no financial conflict of interest for the authors of this study.
References 1. Bankart AS. The pathology and treatment of recurrent dislocation of the shoulder joint. Br J Surg 1938;26:23–9. 2. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability: two to five-year follow-up. J Bone Joint Surg Am 2000;82A:991–1003. 3. Turkel SJ, Panio MW, Marshall JL, Girgjs FG. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am 1981;63:1208–17. 4. Du Toit GT, Roux D. Recurrent dislocation of the shoulder; a twenty-four year study of the Johannesburg stapling operation. J Bone Joint Surg Am 1956;38A:1–12. 5. Bigliani LU, Kurzweil PR, Schwartzbach CC, Wolfe IN, Flatow EL. Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med 1994;22:578–84.
Original article Arthroscopic stabilization for traumatic anterior dislocation of the shoulder: suture anchor fixation versus transglenoid technique JUNG-MAN KIM, YANG-SOO KIM, KEE-YONG HA, and HYUN-MIN CHO Department of Orthopaedic Surgery, Kangnam St. Mary’s Hospital, Catholic University of Korea, 505 Banpo-dong, Seocho-gu, Seoul 137-701, Korea
Abstract Background. The purpose of this study was to evaluate and compare the clinical results of arthroscopic capsulolabral reconstruction using arthroscopic transglenoid fixation and a suture anchor fixation for anterior dislocation of the shoulder. Methods. From December 1999 to September 2006, 46 patients who underwent arthroscopic capsulolabral reconstruction for their anterior dislocation of the shoulder were enrolled, and their surgical outcomes were retrospectively evaluated. In group A (26 patients), the procedure was performed with Caspari’s transglenoid technique. In group B (20 patients), the capsulolabral reconstruction was done using the suture anchor method. The postoperative assessment including American Shoulder and Elbow Surgeons’ (ASES) scores, recurrent instability, the level of return to previous sports activity, and satisfaction with the treatment were compared between the two groups. Statistical analysis was performed using Student’s t-test, chi-squared analysis, and a Pearson correlation coefficient. Results. There were significant differences in ASES scores (group A 76.8 vs. group B 85.5), satisfaction with the surgery (group A 6.5 vs. group B 8.2 — out of 10) and in the level of return to previous sports activity (group A 7.2 vs. group B 8.3 — out of 10) at last follow-up. Recurrent instability occurred in 7 patients in group A (26.9%) and in two cases in group B (10.0%). Conclusions. The arthroscopic capsulolabral reconstruction using a suture anchor was a more reliable treatment option (in regard to satisfaction, functional recovery, and recurrent instability) than the transglenoid fixation technique for anterior dislocation of the shoulder.
Introduction Since Bankart1 first described the lesion observed in patients with recurrent shoulder dislocations, avulsion Offprint requests to: Y.-S. Kim Received: August 2, 2007 / Accepted: March 31, 2008
of the anterior capsulolabral complex from the anterior glenoid has become known to be the main pathology with anterior dislocation of the shoulder. The treatment of anterior dislocation is focused mainly on a Bankart repair with additional tensioning of the inferior glenohumeral ligament, even though the pathological features of this injury include a Bankart lesion, a Hill-Sachs lesion, tear of the inferior glenohumeral ligament, a glenoid fracture, and a rotator cuff tear.2,3 Various techniques have been proposed to repair a Bankart lesion, including an open Bankart repair by drill hole,1 metal staples,4 capsular shift,5 arthroscopic Bankart repair with transglenoid fixation,6 and suture anchoring systems. Even though the open Bankart repair has been considered the gold standard of treatment, recent reports have indicated that arthroscopic repair and reconstruction of the anterior capsulolabral complex provides similar and sometimes superior results with respect to postoperative range of motion compared with the open technique.5,7–9 There are two techniques for an arthroscopic Bankart repair: the transglenoid fixation technique and the anchor fixation technique. Since Caspari6 reported satisfactory results in 96% of 49 patients treated with a transglenoid technique, many authors10–12 have reported various results with the transglenoid fixation techniques. In a meta-analysis of the transglenoid fixation technique, Kandziora et al.13 reported 73.6% (42%–91.3%) of excellent/good results in the Rowe score and an average rate of recurrence of 21.8% (8.7%–49%). Recently, it has been reported that the arthroscopic Bankart repair with suture anchors provides superior stability compared to previous techniques.9,13–15 In a biomechanical study with fresh cadavers, Okamura et al.16 demonstrated that the effective labral depth after an arthroscopic Bankart repair with the suture anchor method was significantly greater than that with the transglenoid methods. In contrast to previous reports, however, Koss et al.15 reported 30% recurrent anterior
J.M. Kim et al.: Arthroscopic fixation of shoulder dislocation
319
instability in patients treated with a suture anchor fixation technique. In a retrospective study to compare the recurrence rates following transglenoid labrum fixation and fixation using the suture anchor technique, Kandziora et al.13 reported that there was no significant correlation between the redislocation rates and the type of surgery. These two techniques are similar in regard to reattachment of the anterior labrum and glenohumeral ligament complex. However, Caspari’s transglenoid technique mainly focuses on suturing the glenohumeral ligament.6 On the other hand, with the anchor technique, the detached anterior labrum is also repaired with the ligament.17 Few reports have compared the two arthroscopic techniques.16,18 The purpose of this study was to compare the clinical results of the transglenoid fixation method and the suture anchor method for treating anterior dislocation of shoulder.
rior working portal, anteroinferior working portal) were established, all internal structures of the involved glenohumeral joint were inspected. In group A, the Caspari’s transglenoid technique was performed with No. 2 ethibond suture (0.9 mm thick); and in group B, suture anchor technique was used with FASTak anchor (Arthrex, Naples, FL, USA). The patient groups was divided chronologically: Caspari’s transglenoid technique (group A) was used between 1999 and 2001, and the suture anchor technique (group B) was used between 2001 and 2006.
Materials and methods From December 1999 to September 2006, a total of 65 patients underwent arthroscopic capsulolabral reconstruction for anterior dislocation of the shoulder at our hospital. Among them, 12 patients were lost to followup; and 46 shoulders in 46 consecutive patients who met the following criteria were included in this study. The patients were divided into two groups according to the operation: the transglenoid fixation technique (group A, 26 patients) and the suture anchor method (group B, 20 patients). All surgical procedures were performed after obtaining informed consent from patients. The average follow-up period was 48.9 months (range 24–95 months). Patients were selected on the basis of the following inclusion criteria: (1) anterior instability as a result of one or more traumatic dislocations that were considered traumatic based on the patient’s history and the necessity of reducing the joint by a physician; (2) subjective symptoms of shoulder instability and a positive apprehension test; (3) arthroscopically confirmed Bankart lesion or capsular laxity. Patients were excluded on the basis of the following criteria: (1) previous operation on the same shoulder; (2) clinical evidence of multidirectional instability or posterior instability. Surgical procedures The arthroscopic stabilization of all patients was performed by one senior author (J.M. Kim). The patients were positioned in the lateral decubitus position for the operation, and while under general anesthesia 5-kg traction force was applied to the operated arm. After three portals (standard posterior viewing portal, anterosupe-
Postoperative management At 2–4 weeks after the operation the patients were allowed to remove the sling intermittently for exercise and start a passive exercise program that included forward flexion to 60°, abduction to 60°, and pendulum exercises. After 4 weeks, all patients began isometric exercises for the deltoid muscle and external rotator as well as active assisted motion exercises with avoidance of external rotation until 8 weeks after surgery. Active motion of all directional and strengthening exercises began at 8 weeks postoperatively. The return to sports activity was permitted 6 months after surgery. Data acquisition We collected the following data retrospectively from the clinical notes: preoperative and postoperative range of motion (ROM) of the shoulder (forward flexion, external rotation at the side, external rotation at 90° abduction, internal rotation) using an universal goniometer in the supine position; age and sex of the patients at the time of surgery; number of dislocations before surgery; chief complaint; cause of dislocation; duration of symptoms before surgery; and early postoperative complications. The operative record was reviewed to evaluate the type of labral lesion, the existence of a Hill-Sachs lesion, concomitant lesions, the number and location of sutures placed in the capsule, and the number and location of suture anchors used for the repair. Determination of the labral lesion type was based on the classification of Adolfsson and Lysholm.19 We obtained the preoperative and postoperative radiographs of the shoulder. Preoperatively, we examined all of the patients with magnetic resonance imaging (MRI) to detect the presence of a Bankart lesion. An attempt was made to contact all 65 patients by telephone or e-mail. Among them, 32 patients who lived locally returned for physical and radiographic examinations. The outcomes of the two procedures were determined based on the following variables: duration until the return to full ROM, recurrence of subjective or
320
J.M. Kim et al.: Arthroscopic fixation of shoulder dislocation
objective symptoms of instability, satisfaction with the procedure, questionnaire results of the American Shoulder and Elbow Surgeons’ (ASES) scoring system,20 return to previous level of sports activity, and complications. We scored the return level to previous sports activity and the satisfaction with the treatment by a Visual Analogue Scale (VAS) scoring system; complete recovery to the preoperative sports level was scored as 10, and complete loss of any sports activity was regarded as 0; in the same manner, complete satisfaction with the treatment was scored as 10, and total dissatisfaction was scored as 0.
The interval from the first dislocation to surgery was <1 year in 11 patients, 1–2 years in 7 patients, and >2 years in 28 patients (range 1 month to 30 years in the two groups).
Statistical analysis Statistical analysis was performed using Student’s t-test and chi-squared analysis, with P < 0.05 considered a significant difference. SPSS version 10.0 software (SPSS, Chicago, IL, USA) supported the statistical evaluation. Pearson’s correlation coefficients were used to detect the variables that correlated with the rate of postoperative recurrent instability symptoms.
Results Characteristics of patients The demographics of the two groups are summarized in Table 1. The variables were not significantly different from each other for the two groups (P > 0.05). Altogether, 46 were included in this study: 43 (93.5%) patients were male, and 3 (6.5%) were female. The average age of the patients was 25.5 years at the time of surgery. All patients had a history of symptomatic anterior dislocation with a positive anterior apprehension test. The average duration of symptoms of instability was 48.7 months before surgery (P > 0.05). The average number of dislocations before surgery was 11.9 (P > 0.05). In the two groups, 16 patients had a history of less than 5 dislocations, 9 patients reported 5–10 dislocations, and 21 patients reported >10 dislocations.
Range of motion Surgical results are summarized in Table 2. Postoperative ROM of the shoulder was fully recovered in most of the patients. The average duration for complete recovery of ROM after surgery was 5.4 months (P > 0.05). However, three patients (6.5%) — two patients in the transglenoid group one patient in the suture anchor group — demonstrated a mean loss of external rotation of 15.3° at the side (range 17.5°–9.3°) and 9.2° in the abduction position (range 12.2°–5.5°) compared with the opposite shoulder at the last follow-up. Postoperative function The ASES scores of the suture anchor group (average 85.5, range 69–99) were significantly higher than those of the transglenoid group (average 76.8, range 40–99) at the time of the last follow-up (P < .05) (Table 2). The average satisfactory score for the treatment was 6.5 (range 2.5–9.0) in the transglenoid group and 8.2 (range 6–10) in the suture anchor group (P < 0.05). The average score for return to the previous level of sports activity was significantly higher in the suture anchor group (8.3, range 6–10) than that in the transglenoid group (7.2, range 4–9) (P < 0.05). Recurrent instability If the patients complained of instability symptoms without objective evidence of recurrent instability, we included them in the failed cases. All failed cases had a positive anterior apprehension test and positive anterior drawer signs on physical examination. Recurrent instability occurred in seven cases (26.9%) in the transglenoid group (group A) and two cases (10.0%) in the suture anchor group (group B) (Table 3). Only one
Table 1. Demographics of the patients Variables No. of patients Age at operation (years) Sex (men/women) Age at onset (years) No. of dislocations before operation Duration of symptoms before operation (months) Postoperative follow-up (months) All values are averages
Transglenoid repair (group A)
Suture anchor repair (group B)
P
26 26.7 24/2 22.0 11.4 55.9 56.4
20 24.3 19/1 20.9 12.3 41.4 41.4
0.41 0.86 0.67 0.86 0.48 0.02
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321
Table 2. Operative results Variables Concomitant SLAP Time to return to full ROM (months) Labral lesion A B C Hill-Sachs lesions (no. of cases) No. of sutures/fixation No. of failed cases D/L S/L Total Postoperative recurrence period (months) ASES score Satisfaction with treatment Return to sports activity level score
Transglenoid fixation (group A)
Suture anchor fixation (group B)
P
6 cases 5.6
7 cases 5.1
0.57 0.39
13 5 8 21/26 (80.8%) 5.1
9 3 8 14/20 (70.0%) 4.9
0.73 0.55
2 5 7/26 (26.9%) 20.2 76.8 6.5 7.2
0 2 2/20 (10.0%) 16 85.5 8.2 8.3
0.044
0.047 0.002 0.005
SLAP, superior labrum anterior posterior; ROM, range of motion; D/L, dislocation; S/L, subluxation; ASES, American Shoulder and Elbow Surgeons
patient, who sustained a recurrent dislocation, had undergone open surgical stabilization at our hospital. The average satisfaction score with treatment of the patients with recurrent instability was 6.1 (highest possible score is 10), and the average return level to previous sports activity was 6.9 (highest possible score is 10). There was no significant correlation (correlation coefficient ≥0.4) between the postoperative recurrence of instability and several variables, including the patient’s age at the time of surgery, age at first dislocation, concomitant superior labrum anterior and posterior (SLAP) lesion, number of dislocations before surgery, duration of symptoms before surgery, time to the return to full ROM, type of Bankart lesion, existence of a Hill-Sachs lesion, and number of fixation points and anchor screws (P < 0.05).
Discussion This study demonstrated that arthroscopic stabilization using a suture anchor was an effective surgical technique for anterior dislocation of the shoulder. We believe that the low satisfactory score in the transglenoid group was due to the high recurrence rate of the instability after surgery. These results revealed that patients who underwent surgery with the suture anchor technique were more satisfied with the results and could return to their previous level of sports activity more easily than those who underwent the transglenoid technique. Postoperative ROM of the shoulder was fully recovered in most of the patients in our series. We found that the excellent restoration of ROM was one of the advantages of the arthroscopic procedures.
Various rates of recurrent instability after arthroscopic stabilization, ranging from 4% to 60%, have been reported. 6,14,15 Walton et al.21 reported, based on a metaanalysis study, that the redislocation rates for the transglenoid technique were higher than those reported for the anchor technique (15% vs. 7%). In addition, they stressed the important roles of the capsule and labrum, which are vitally important to maintain shoulder stability. We believe that the difference in recurrence rates between the two groups resulted from two technical points. First, with Caspari’s technique, even though several sutures pass through the capsule and labrum, all the structures are fixed at only one point on the anterior glenoid; in contrast, with the suture anchor technique, every stitch of the capsule and labrum is fixed to the corresponding site on the anterior glenoid. Second, with the transglenoid fixation technique, the strands passing through the capsulolabral complex make a long tract from the anterior glenoid to the medioinferior border of the scapula in the infraspinatus fossa. In other words, the distance from the suture site of the capsulolabral structure to the fixation site on the bone is exceedingly long with the transglenoid fixation method, and this type of fixation may easily lose its holding capacity of the capsule. In previous reports, the recurrence rate for instability after surgery was correlated with patient age, number of preoperative dislocations, and the type of the labrum lesion.12,13,15 However, we could not find any significant correlation of recurrent instability with these factors. We believe that recurrence of instability after surgery depends on the technique and method of surgery, rather than other factors. There are some limitations of this study. There is a potential for bias, as the study was retrospective, with
M 21
M 18
M 18
F
M 21
M 25
M 23
3
4
5
6
7
8
9
F/U, follow-up
Average
M 20
2
21.2
24
M 21
1
Case
18.9
21
22
17
24
17
17
18
19
15 1 3 5 30 4 2 7 11
− − + − − − + − 8.1
10
−
23
12
18
5
17
57
52
20
9
17
No. of Time from Age at D/L operation to before recurrence first Sex Age D/L SLAP surgery (months)
Table 3. Summary of patients with recurrent instability
Slip down (S/L) No special event (S/L) Ski injury (D/L) Swimming (S/L) Volleyball (D/L) No special event (S/L) No special event (S/L) No special event (S/L) No special event (S/L)
Reason for recurrence
−
−
−
−
+
−
−
−
−
B
B
A
A
A
A
A
A
A
53.2
32
24
53
41
82
84
73
49
41
5.3
5
4
5
4
6
3
8
7
6
C
A
A
C
C
C
C
A
A
+
+
−
−
+
+
+
+
+
5
5
5
4
6
5
5
5
6
4
70.7
84
83
69
77
60
76
40
77.5
70
6.1
7
7
6
8
2.5
6
5
8
5
6.9
7
7
7
9
4
6
7
7.5
8
F/U period after Time to Type of HillSecond operation full ROM labral Sachs No. of ASES Sports operation Group (months) (months) lesion lesion fixations score Satisfaction level
322 J.M. Kim et al.: Arthroscopic fixation of shoulder dislocation
J.M. Kim et al.: Arthroscopic fixation of shoulder dislocation
323
no randomization when selecting the patients. The follow-up periods were different between the two groups. We recognized that this difference in the evaluation period can influence the outcome, especially the recurrence of instability. However, all recurrent instability symptoms of the failed patients in our series occurred within 20 months after surgery, except for two patients who suffered from new trauma.
6. Caspari R. Arthroscopic reconstruction for anterior shoulder instability. Oper Tech Orthop 1988;3:59–66. 7. Guanche CA, Quick DC, Sodergren KM, Buss DD. Arthroscopic versus open reconstruction of the shoulder in patients with isolated Bankart lesions. Am J Sports Med 1996;24:144–8. 8. Sperling JW, Duncan SF, Torchia ME, O’Driscoll SW, Cofield RH. Bankart repair in patients aged fifty years or greater: results of arthroscopic and open repairs. J Shoulder Elbow Surg 2005; 14:111–3. 9. Fabbriciani C, Milano G, Demontis A, Fadda S, Ziranu F, Mulas PD. Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy 2004;20: 456–62. 10. Ekelund A, Nyberg R. Arthroscopic shoulder stabilization using transglenoid sutures. Scand J Med Sci Sports 1998;8:416–20. 11. Pagnani MJ, Warren RF, Altchek DW, Wickiewicz TL, Anderson AF. Arthroscopic shoulder stabilization using transglenoid sutures: a four-year minimum follow up. Am J Sports Med 1996; 24:459–67. 12. Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S. Arthroscopic stabilization for recurrent anterior shoulder dislocation: results of 59 cases. Arthroscopy 1995;11:173–9. 13. Kandziora F, Jäger A, Bischof F, Herresthal J, Starker M, Mittlmeier T. Arthroscopic labrum refixation for post traumatic anterior shoulder instability: suture anchor versus transglenoid fixation technique. Arthroscopy 2000;16:359–66. 14. Kim SH, Ha KI, Kim SH. Bankart repair in traumatic anterior shoulder instability: open versus arthroscopic technique. Arthroscopy 2002;18:755–63. 15. Koss S, Richmond JC, Woodward JS Jr. Two- to five-year followup of arthroscopic Bankart reconstruction using a suture anchor technique. Am J Sports Med 1997;25:809–12. 16. Okamura K, Takiuchi T, Aoki M, Ishii S. Labral shape after arthroscopic Bankart repair: comparisons between the anchor and Caspari methods. Arthroscopy 2005;21:194–9. 17. Wolf EM, Wilk RM, Richmond JC. Arthroscopic Bankart repair using suture anchors. Oper Tech Orthop 1991;1:184–91. 18. Romeo AA, Cohen BS, Carreira DS. Traumatic anterior shoulder instability. Orthop Clin North Am 2001;32:399–409. 19. Adolfsson L, Lysholm J. Arthroscopy and stability testing for anterior shoulder instability. Arthroscopy 1989;5:315–20. 20. Richards RR, An KN, Bigliani LU, Friedmann RJ, Gartsman GM, Gristina AG, et al. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994;3: 347–52. 21. Walton J, Paxinos A, Tzannes A, Callanan M, Hayes K, Murrell GA. The unstable shoulder in the adolescent athlete. Am J Sports Med 2002;30:758–67.
Conclusion Precise assessment of the pathological structure of the instability and meticulous technique when reconstructing the capsulolabral structure can produce a satisfactory outcome and reduce the rate of complications in cases of instability. Acknowledgment. This work received a JOA Travel Award at the 79th annual congress of the Japanese Orthopaedic Association, Yokohama, May 2006. There was no financial conflict of interest for the authors of this study.
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