ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR TRAUMATIC ANTERIOR SHOULDER INSTABILITY

MANAGEMENT OF THE UNSTABLE SHOULDER ARTHROSCOPIC 0278-5919/00 $8.00 APPROACHES FOR THE NEXT MILLENNIUM

+ .OO

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR TRAUMATIC ANTERIOR SHOULDER INSTABILITY Brian J. Cole, MD, and Jon J. P. Warner, MD

Techniques for the arthroscopic treatment of patients with recurrent shoulder instability have flourished despite several early reports indicating greater failure rates compared with traditional open stabilization techniques. Proponents of arthroscopic stabilization cite its advantages as including more accurate identification of intra-articular pathology, less morbidity, improved cosmesis, faster recovery, and, possibly, greater returns in postoperative motion. Disadvantages include complications inherent to the technique applied, requisite technical skill, a potential lack of versatility to treat a spectrum of pathology, and generally higher failure rates. As the knowledge of the basic science behind the pathophysiology of shoulder instability improves and as more clinical reports emerge, the exact indications for arthroscopic stabilization are gradually being refined. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. ~~

From the Department of Orthopaedics, Rush Medical College of Rush University; and the Section of Sports Medicine, Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Illinois (BJC); and the Department of Orthopaedic Surgery, Harvard Medical School; and The Harvard Shoulder Service, Massachusetts General Hospital, Boston, Massachusetts (JJPW)

CLINICS IN SPORTS MEDICINE VOLUME 19 * NUMBER 1 *JANUARY2000

19

20

COLE & WARNER

Various definitions of success following shoulder stabilization are defined by the literature. When recurrent instability is the benchmark, failure rates vary by technique. For example, recurrences following arthroscopic stapling range between 3% and 33%.* Reports of failures following arthroscopic transglenoid suturing techniques range between 0% and 44%.t Reports of failures following the application of a bioabsorbable tack range between 0% and 21%.=, 70, 98,lZ1, 137,138 Arthroscopically placed suture anchors, a relatively new technique, has similar failure rates.7,11, 36. 49, 56 The literature is replete with reports of open stabilization indicating failure rates that are generally less than lo%.$ To date, only a few series reporting direct comparisons between arthroscopic and open techniques exist.25,40, 45, 48, 49, 123, 141 Critical analysis of the available literature reveals several interesting features. Many reports include patients treated by mixed techniques applied to mixed pathology and origin at the time of the index procedure. Finally, outcome scales often differ between reports, and the definition of failure is variably defined. This article defines the anatomic considerations for shoulder stability! the classification of shoulder instability, and the primary pathology associated with traumatic anterior shoulder instability. Understanding the pathoanatomy associated with traumatic anterior shoulder instability is critical to determining the appropriate indications for either arthroscopic or open stabilization. A summary of the history of open and arthroscopic techniques and contemporary clinical outcomes is provided. Finally, the indications and the authors' algorithm used to treat traumatic anterior shoulder instability by either open or arthroscopic means based on the authors' clinical experience is presented.

ANATOMY OF SHOULDER STABILITY

The normal stabilizing structures of the glenohumeral joint are diverse and are summarized in detail by Cole and Warner." A synthesis of concepts derived from the basic science investigating the static and dynamic stabilizers of the glenohumeral joint is of primary importance to understand the pathophysiology of traumatic anterior shoulder instability and effect treatment. Because the large, spherical head of the humerus articulates with a relatively small and shallow glenoid, the glenohumeral joint requires *References 17, 28, 29, 48, 53, 65, 69, 78, 99, 115, 142 tReferences 15, 20, 32, 38, 40, 43, 44, 68, 81, 85, 91, 105, 111, 142, 148, 149 $References 1,31, 57, 62, 83, 97, 106, 108, 110, 145

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

21

several mechanisms to maintain stability while providing for a large range of motion. Static and dynamic stability is provided by the combined effects of the capsuloligamentous structures, the rotator cuff, the scapular stabilizers, and the biceps muscle. In the midranges of rotation, most joint stability is through the dynamic action of the rotator cuff and biceps tendons through concavity compression of the humeral head within the glenoid socket. The ligamentous structures function at only the extreme positions of rotation, preventing excessive rotation and translation. Contraction of the muscles around the shoulder and proprioceptive feedback may act secondarily by protecting the relatively weak ligamentous structures from being overwhelmed from excessive tension. The relative lack of depth and surface area of the bony glenoid is compensated for by the fibrous labrum acting to maintain normal glenohumeral biomechanics. As determined by Cooper et the labrum is a fibrous ring attaching to the glenoid articular cartilage through a narrow fibrocartilaginous transition zone. Above the glenoid equator, the labrum is relatively more mobile. In contrast, below the equator, the labrum is more tightly attached to the glenoid articular cartilage. The labrum provides an attachment site for the glenohumeral ligaments and the tendon of the long head of the biceps. Its principal function is to increase the depth of the glenoid socket and to act as a "chock block," preventing the head from rolling over the anterior edge of the glenoid. Virtually all labral lesions, especially those below the glenoid equator, are thought to be associated with glenohumeral instability. Plastic deformation, capsular rupture, abnormal laxity, periosteal capsular stripping, or any combination of these lesions may also be associated with complete dislocation with or without the Bankart lesion. The role of the capsule and ligaments in preventing instability is complex and depends on shoulder position and the direction of the applied force. In general, the anterior capsule becomes more important during extension and the posterior capsule during flexion. The inferior capsular structures are most functional near full elevation and the superior capsular structures near full adduction. Extremes of internal and external rotation have the effect of winding up the capsular structures leading to joint compression and increased stability caused by tension developing in the relevant structures. The inferior glenohumeral ligament (IGHL) complex is the primary static check against anterior, posterior, and inferior translation between 45" and 90" of glenohumeral elevation. The superior glenohumeral ligament and middle glenohumeral ligament (MGHL) limit anteroposterior and inferior translation in the middle and lower ranges of elevation as the arm approaches the adducted position. Experimentally, posterior translation in the flexed, adducted, and internally rotated positions may require disruption of the anterosuperior capsule in addition to the poste-

22

COLE & WARNER

rior structures. The superior glenohumeral ligament, coracohumeral ligament, and IGHL probably function together to limit inferior translation of the adducted shoulder and act as secondary restraints against posterior translation. Clinically, these structures are addressed during either arthroscopic or open reconstruction, but simply overtightening the capsule to limit the end-ranges of motion to achieve stability may lead to pathologic limitation of shoulder motion and late arthrosis. The rotator interval region between the subscapularis and supraspinatus muscles may be associated with abnormal translation, especially inferior translation of the adducted arm and, possibly, anteroposterior translation. Contraction of the rotator cuff and long head of the biceps brachii affects static and dynamic factors that enhance stability. Primarily, they act in concert to increase compression across the glenohumeral joint, increasing the loads required to translate the humeral head. These factors are especially important in the mid-ranges of motion, where the capsuloligamentous structures are more lax. The scapulothoracic stabilizers help to accurately time and position the glenoid beneath the humeral head. Dysfunction in any of these stabilizers can lead to subsequent instability as residual stabilizing mechanisms become overwhelmed. Proprioceptive mechanisms help to coordinate and time this system and are restored after surgery to correct instability. The effects of abnormal articular surfaces, articular version, negative intra-articular pressure, and adhesion-cohesion in part or in combination can lead to or worsen shoulder instability, but alone they may have only a negligible role in the pathogenesis of shoulder instability. Rarely is bone loss sufficiently significant to warrant surgical correction. Unfortunately, clinical data are lacking for most of these factors, and an algorithmic approach to their treatment is evolving as experimental models improve.

CLASSIFICATION OF SHOULDER INSTABILITY

Instability of the shoulder has been classified according to four major criteria: I. Degree A. Dislocation B. Subluxation C. Subtle 11. Frequency A. Acute (primary) B. Chronic 1. Recurrent 2. Fixed

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

23

111. Origin A. Traumatic (macrotrauma) B. Atraumatic 1. Voluntary (muscular) 2. Involuntary (positional) C. Acquired (microtrauma) D. Congenital E. Neuromuscular (Erb’s palsy, cerebral palsy, seizures) Iv. Direction A. Unidirectional 1. Anterior 2. Posterior 3. Inferior B. Bidirectional 1. Anteroinferior 2. Postinferior C. Multidirectional Thomas and MatsenI2*originally introduced the acronyms TUBS and A M B X I to help physicians think about the origin and treatment of most patients who have shoulder instability. The TUBS variety of instability describes patients with macrotraumatic unidirectional instability associated with a Bankart lesion that typically responds well to surgery. The AMBRI variety of instability describes a patient with atraumatic, multidirectional instability that is bilateral and often responds to rehabilitation; rarely, this type of instability requires an inferior capsular shift with or without rotator interval closure. Physicians now recognize that shoulder instability is a continuous pathoanatomic spectrum with significant overlap between groups. For the purposes of this article, the authors consider patients with acute and chronic traumatic anterior shoulder instability the most common form of shoulder instability.

PATHOLOGY OF TRAUMATIC ANTERIOR SHOULDER INSTABILITY Glenoid Labrum and the Bankart Lesion pert he^^^ and Bankart9 (hence, the Perthes-Bankart lesion) originally described the detachment of the capsulolabral complex from the glenoid rim and scapular neck as the ”essential lesion” leading to recurrent anterior dislocation. A Bankart lesion is a lesion of the labrum corres-

24

COLE & WARNER

ponding to the detachment of the anchoring point of the IGHL and MGHL from the glenoid rim.9,lo6 A Bankart lesion disrupts the concavity-compression effect during rotator cuff contraction, eliminates the "chock-block" effect, and decreases the depth of the socket by 50% with detachment of the capsuloligamentous structures. Lippitt et al" demonstrated that resection of the labrum reduced resistance to translation by 20%. Lazarus et al7I determined that by creating a chondral-labral defect, an 80% reduction in the height of the glenoid occurred, with a concomitant reduction in the stability ratio of 65% in the direction of the defect. This lesion is often confused with normal anatomic variants (e.g./ a sublabral sulcus underneath a cordlike MGHL or a loosely attached labrum superiorly). Whether the Bankart lesion is the "essential lesion" leading to recurrent anterior instability is a topic of interest. Isolated detachment of the labrum as a singular entity leading to recurrent instability has been challenged by several investigators.61,122, 132 Speer et allz2found that simulation of the Bankart lesion in cadaveric cutting studies resulted in only minimal increases in anterior translation. Despite this controversy, the Bankart lesion commonly occurs in association with traumatic anterior shoulder instability. Taylor and ArcierolZ7studied first-time traumatic anterior shoulder dislocators and determined arthroscopically that 97% had evidence of isolated detachment of the capsuloligamentous complex from the glenoid rim and neck without evidence of intracapsular injury. Others have noted a similarly high incidence of Bankart lesions at the time of surgery.55,88 The Bankart lesion is commonly present following traumatic anterior shoulder dislocation and is uniformly recognized as a relevant anatomic consideration requiring repair during open or arthroscopic reconstruction.

Anterosuperior Labrum Pagnani et a194demonstrated the importance of the superior portion of the glenoid labrum. In a cadaver study, isolated lesions of the anterosuperior portion of the labrum did not have a significant effect on glenohumeral translation, but complete lesions of the superior portion of the labrum associated with destabilization of the biceps insertion resulted in significant increases in anteroposterior and superoinferior glenohumeral translations in the lower and middle ranges of elevation. The implications of these findings are that destabilization of the glenoid insertions of the superior glenohumeral ligament, MGHL, and biceps insertion may be associated with subtle increases in translation and may be related to the symptoms present in patients who have isolated lesions of the superior labrum or in combination with a Bankart lesion.94,lI7

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

25

Thus, at the time of surgery, all labral lesions must be addressed, and the failure to do so may lead to residual instability.

Capsule Investigators now believe that recurrent complete dislocation is associated with capsular plastic deformation or ~tretch.'~, 'I9, lZ9 Plastic deformation or capsular injury in first-time dislocators may not be appreciated by macroscopic evaluation and may represent microscopic ultrastructural failure. Respecting this concept is clinically important. In part, failure to address capsular laxity at the time of arthroscopic repair may explain higher failure rates in some series2,25, 69, 121, 135 Conversely, open Bankart procedures that address only the labral detachment may create sufficient capsular scarring to prevent recurrence. These tenets become more complex in patients with multidirectional instability in which capsular laxity is the dominant pathology and labral lesions are less frequently found. As is discussed later, thermal methods using radiofrequency or laser may be used to treat residual capsular laxity following arthroscopic Bankart repair. Sometimes macroscopic rupture of the capsule also occurs. Symenoideslz5observed that 15%of his patients treated for anterior dislocation had labral detachment and anterior capsular ruptures. Johnson64observed that 54% of patients had torn glenohumeral ligaments at the time of arthroscopy for anterior dislocation. Disruption of the lateral capsule from the humeral neck is probably rare but has been reported in association with anterior dislocation.6,lz7, 136 Wolf et coined the term HAGL lesion, representing humeral avulsion of the glenohumeral ligaments. The so-called BHAGL lesion has also been described and, like the HAGL lesion, is essentially an indication for open repair.89

Rotator Interval The rotator interval subtends a medially based triangular space bordered superiorly by the anterior margin of the supraspinatus tendon, inferiorly by the superior border of the subscapularis tendon, medially by the base of the coracoid, and laterally by the long head of the biceps tendon and sulcus. The floor of the rotator interval is normally bridged by capsule. Occasionally, a complete opening within the tissue spanning the rotator interval is present and is described as a "rotator interval capsular defect." The capsule, when present, is the thinnest region of the joint capsule.23,37. 52. 58, 60, 86. 87 Openings within the rotator interval have been associated with

26

COLE & WARNER

recurrent anteroinferior and multidirectional in~tability.~~, 86 Addressing this pathologic condition may be important in preventing recurrence. Conversely, contracture or scarring of this portion of the shoulder capsule has been associated with adhesive c a p s ~ l i t i s . ~ ~ 527

Humeral Bone Loss

Articular abnormalities of the humeral head can disrupt the anatomic relationship of the glenohumeral joint, predisposing it to recurrent instability. A large Hill-Sachs or reverse Hill-Sachs impression fracture on the posterolateral and anterolateral margin of the humeral head, respectively, is created when the humeral head dislocates over the anterior or posterior glenoid rim. This lesion is present in more than 80% of anterior dislocations and 25% of anterior subluxations.l8T95 Small HillSachs lesions are not usually thought to be a major contributor to recurrent anterior instability. Relatively small lesions may be prevented from contacting the anterior glenoid rim simply by performing a more generous anterior capsulorrhaphy. Caution is warranted because excessively tight anterior rel6 pairs may be associated with the development of late arthr~sis.'~, When the Hill-Sachs lesion involves more than 30% of the humeral articular surface, it may contribute to recurrent anterior instability, even with capsular repair.lo7, Surgical treatment of patients with these defects involves filling the defect with allograft bone4" 63; muscle tendon transferz6,79 (e.g., infraspinatus or subscapularus); or, in older individuals, humeral head replacement. Alternatively, the lesion can be rotated out of contact with the glenoid with proximal humeral oste~tomy.'~~ Glenoid Bone Loss

Bony lesions of the anterior or posterior glenoid rim are believed by some to be sufficiently important to be formally reconstructed during open capsulorrhaphy. These lesions are caused by osseous Bankart lesions or wear related to repeated instability. Pavlov et a195described the occurrence of osseous Bankart lesions in 15% of patients with recurrent anterior dislocation and in approximately 50% of patients with recurrent anterior subluxation. The overall aim of any reconstructive procedure directed at larger glenoid defects is to deepen the socket and support the capsule. Glenoid defects less than 20% are rendered extra-articular by repairing the capsule and labrum back to the edge of the intact glenoid. Larger fragments are mobilized and reconstructed through traditional means. GerbeP and

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

27

others124advocate intra-articular iliac bone graft to reconstruct the glenoid cavity before capsular repair when at least 25% of the glenoid surface is involved. Unlike the Hill-Sachs lesion, few data are available to suggest which glenoid defects require reconstruction, repair, debridement, or neglect.

EVOLUTION OF LABRAL REPAIR

The initial description of labral repair included passing sutures through bone tunnel^.^ Because of the relatively demanding nature of this technique, alternatives were developed. As outlined in Table 1, the history of labral fixation techniques has evolved considerably to include open placement of transglenoid sutures and arthroscopic placement of sutures, staples, rivets, screws, and bioabsorbable tacks.

RESULTS FOLLOWING OPEN AND ARTHROSCOPIC STABILIZATION

Performed as an adjunct to open shoulder stabilization, arthroscopy allows improved visualization of the capsuloligamentous complex and identification of other articular lesions,s but to be an effective alternative to open stabilization, an arthroscopic stabilization procedure must meet several criteria. The success and failure rates must be similar, the technique must allow the surgeon to address multiple lesions, and the

Table 1. HISTORICAL OVERVIEW OF THE METHODOLOGY USED FOR LABRAL FIXATION Procedure

Open Bone tunnels Staples Transglenoid Suture anchors Arthroscopic Staples Rivets Suture anchors Transglenoid sutures Bioabsorbable tacks

Year

Reference

1938 1956 1949 1959 1982 1994

9 33 74 134 100 72

1982 1988 1991 1987 1988 1991 1991 1993

64 143 146 82 81 75 124 118

28

COLE & WARNER

procedure must be reproducible. To date, no single arthroscopic technique completely meets these requirements. Evaluation of outcomes following arthroscopic stabilization is fraught with series containing mixed populations with varied indications, instability patterns, arthroscopic findings, and techniques. Arthroscopic stabilization will always be held to what many believe is the standard against which other procedures are measured-open stabilization. The best results following arthroscopic stabilization with satisfactory follow-up demonstrate recurrence rates of 4% to 8%.20, 146 Most other series reflect the difficulty in reproducing these results. Open reconstruction is a versatile procedure capable of addressing detachment lesions and capsular pathology when necessary. Rowe et allo6reported on the open Bankart repair with a 96.5%success rate. Many other reports on open Bankart reconstruction have success rates ranging from 91% to 97%: but return to high-level activities has had less promising results following open stabilization. For example, Bigliani et all4noted that only 67%of throwing athletes returned to their normal activity level following open capsular shift. Reports of loss of motion are of even more concern 55, following open stabilization.54*

Arthroscopic Techniqus Staples

The earliest attempts at arthroscopic treatment involved staple capsulorrhaphy as introduced by JohnsonM in 1982. Results following arthroscopic staple capsulorrhaphy vary, with recurrence rates ranging between 3% and 33% (Table 2). A review of the literature demonstrates several series of relatively pure populations of patients with chronic recurrent traumatic anterior instability. The technique is associated with a relatively high complication rate of between 5% and 115 Complications inherent in the use of arthroscopically placed staples include staple bending, breakage, intraarticular penetration, migration, loosening, infection, and painful bursitis developing between the staple and s u b s ~ a p u l a r i sFurthermore, .~~~ staple capsulorrhaphy is essentially a single-point fixation that lacks the ability to address capsular laxity. Because of the relatively high failure rate and its inherent complications, staple capsulorrhaphy is less frequently performed. *References 1, 31, 57, 62, 83, 97, 106, 108, 110, 145

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

29

Table 2. ARTHROSCOPIC BANKART REPAIR WITH STAPLE TECHNIQUE

Study

Mathews (1988)78 Hawkins (1989)53 Wheeler (1989)142 Gross (1989)"" Burger (1990)17 Coughlin (1992)28 Detresac (1993)29 Lane (1993)69 Wilson (1993)l" Johnson (1993)65 Rao (1994)Kempf (1994)66

Sample Size

Mean Follow-up (mo)

Recurrence

("w

Comments

25 50 6 12 52 47 148 54 101 124 22 42

33 39 >14 45 25 48 49 39 16 36 28 32

12 16 16 16 13 25 11 33 27 14 26 7

Staple impingement 5% loosening Staple impingement 5% loosening 6% painful staples 10% removal 15% loosening 47% with pain 60% with pain 38% with pain

Transglenoid Sutures

In 1987, Morgan and Bodenstabs2described the two-pin transglenoid arthroscopic technique for suturing the labrum through a transglenoid drill hole. Since then, several investigators, including Caspari,19 have modified and popularized the transglenoid suture technique, with recurrence rates ranging between 0% and 44% (Table 3).* Most series reflect mixed populations with varied instability patterns. This procedure has the added advantage of the ability to place multiple sutures and address capsular laxity. Disadvantages include the passage of a drill posteriorly and tying the sutures over the fascia, placing the suprascapular nerve at risk. Cannulated Bioabsorbable Implants

Several investigators report excellent results following the use of cannulated bioabsorbable implants (i.e., the Suretac, Acufex Microsurgical, Norwood, MA) to secure the anterior labrum and IGHL complex to the anterior glenoid. Reports of failures following the application of a 70,98, 121, 137, 138 bioabsorbable tack range between 0% and 21% (Table 4).25, Even the most refined indications lead to recurrence rates of 10% to 16%.25,70 Most series report on relatively pure populations of traumatic anterior instability, with special emphasis on management in the acute setting. Advantages include a relatively short learning curve and good results when the repair involves simple labmm reattachment. Disadvantages include the limited ability to address capsular laxity and the *References 15, 20, 32, 38, 40, 43, 44, 68, 81, 85, 91, 105, 111, 142, 148, 149

30

COLE & WARNER

Table 3. ARTHROSCOPIC TRANSGLENOID SUTURE CAPSULORRHAPHY

Study

Savoie (1997)"' Manta (1997)76 Torchia (1997)l3I Mologne (1996)"O Maracci (1996)" Youssef (1995)149 Green (1995r' Pagnani (1994)93 Walch (1994)135 Arciero (1994)5 Foster (1994)38 Goldberg (1993)43 Grana (1993)M Benedetto (1992)12 Landseidl (1992)68 Morgan (1991)81 (1991) Caspari (1991)'O Rose (1990)'05 Weber (1990)141 Wolin (1990)148 Morgan (1987)82

Sample Size

161 29 150 48 29 42 30 47 37 59 21 75 38 27 31 65 55 120 49 50 23 45 25

Mean Follow-up (ma

Recurrence (%.)

58

9 17 7 41 27 5 27 42 19 40 14

> 60 49 30 59 38 38 41 67 49 32 12-84 36 36 24 35 49 12-36 24-72 > 24 27 > 24 17

8

10 44 0 11 4 6 4 4 17 27 0

inadequate fixation of poor quality capsuloligamentous structures caused by single-point fixation. A unique complication associated with this implant is a 6% incidence of intracapsular synovial reaction that generally responds well to arthroscopic lavage, debridement, and intraarticular

Suture Anchors Arthroscopic placement of suture anchors with absorbable sutures was initially described by This technique was later modified by Table 4. ARTHROSCOPIC CANNULATED BIOABSORBABLE IMPLANT

Study

Sample Size

Mean Follow-up (mo)

Recurrence (%.)

Resch (1997)'02 Speer (1996)122 Laurencin (1996)'O Arciero (1995)4 Arciero (1995)3 Resch (1992)'01 Warner (1991)138 Warner (1991)13'

53 52 19 19 63 18 26 20

35 42 37 19 > 24 11 > 24 32

9 21 10 0 13 6 8 10

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

31

Snyder,116who used permanent sutures. Only a few series have reported the results of this technique with failure rates ranging between 0% and 33% (Table 5).7,11, 36, 49, 56, lz3 The advantages of suture anchor placement are similar to the tranglenoid suture technique, but the posterior drilling is avoided. Disadvantages include the technical difficulty in passage of sutures through soft tissues and arthroscopic knot tying. Anchor cost is an additional disadvantage. Complications caused by suture anchors include suture breakage, knot abrasion within the glenohumeral joint, anchor malposition, suture unloading from the anchor, anchor pull-out, and instrument failure. Similar to staples, loosening and migration of metal suture anchors has been reported to cause articular cartilage damage.35The use of suture anchors in open reconstruction was correlated with higher failure rates compared with traditional transosseous techniques.lZ6These investigators suggested that the presence of the suture between the labrum and bony glenoid may have prevented adequate healing between the reattached capsule and bone. Infections caused by suture anchors are essentially limited to case Because arthroscopic placement of suture anchors is a relatively new technique, clinical reports are lacking. With the instrumentation available today supplementing the use of suture anchors and the ability to arthroscopically address capsular laxity, relatively low recurrence rates will probably be reported in subsequent series. Independent of the technique, the ultimate success of any reconstructive procedure used to treat labral pathology will depend on the biologic healing of soft tissue to bone. Comparisons of Arthroscopic and Open Stabilization

Only a few reports have compared the results of arthroscopic and open stabilization in a relatively pure population of patients with traumatic anterior instability (Table 6). Field et a136reported the comparative

Table 5. ARTHROSCOPIC SUTURE ANCHORS Sample Size

Mean Follow-up (mo)

Recurrence

Study

("/I

Comments

Field (1999)36 Sisto (1998)lI4 Bacilla (1997)7 Hoffman (1995)56 Guanche (1996)"9 Belzer (1995)" Wolf (1993)146

50 27 40 30 25 37 50

33 47 30 24 27 22 "Short"

8 13 7 11 33 11

Comparative series Refined indications High demand patients Comparative series 13% apprehension No formal results

0

32

COLE & WARNER

Table 6. COMPARISONS BETWEEN ARTHROSCOPIC AND OPEN STABILIZATION Recurrence Study

Mean Follow-up ( N O ) (mo)

A

0

50150

33 / 30 52 / 55 36 / 40 27/25 23 I 2 4

8 16 17 33 43

0 9 5 8 0

Field (1999)36 Cole (1999)25 Steinbeck (1998)'= Guanche (1996)49 Geiger (1993)'O A

=

(W

Sample Size (NO) 37/22 30 I 3 2 25/12 16/18

arthroscopic; 0 = open.

results following arthroscopically placed suture anchors to open Bankart repair. Cole et a125reported on the bioabsorbable tack compared with open stabilization. Steinbeck and J e r ~ s c hcompared '~~ transglenoid stabilization with open anchor stabilization. Guanche et al" reported on the use of transglenoid sutures and suture anchors compared with open Bankart repair. Finally, Geiger et a P reported on comparisons between arthroscopic transglenoid suture placement and open stabilization. All of these series demonstrate trends or statistically significant differences favoring open versus arthroscopic stabilization when recurrence rates are the primary outcome measured. Complication rates and surgical morbidity were compared by Green and Christen~en?~ who noted that arthroscopic stabilization was associated with a 1.8-fold decrease in surgical time, a 10-fold decrease in blood loss, and a 2.5-fold decrease in postoperative narcotic use compared with the open procedure. Barber et allodetermined that the arthroscopic Bankart repair was performed more quickly and resulted in lower total charges compared with open Bankart repair. To date, no truly randomized prospective study with an absolutely pure patient population has compared the arthroscopic and open stabilization techniques. PATIENT SELECTION History and Physical Examination

A thoughtful and detailed history and physical examination are the most important tools available to evaluate glenohumeral instability. Historical information includes details surrounding the onset, duration, and frequency of symptoms. Discerning the traumatic nature of instability and ruling out any volitional component are critical to the ultimate success in treating patients with traumatic anterior instability. Arm position at the time of the initial injury and methods required to reduce the

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

33

dislocation give clues to the extent of the intra-articular injury. Responses to previous treatment, including rehabilitation and activity modification, are sought. Comprehensive questioning regarding the nature and location of a patient’s pain and disability is performed. Catching or audible ”clicks” or ”pops” may suggest a displaced labral tear. Physical examination usually confirms the suspected diagnosis from a patient’s history. The presence of muscle atrophy and ligamentous laxity is noted. Side-to-side comparisons of the amount of glenohumeral translation in the anterior, posterior, and inferior directions are made. Provocative testing, including testing for apprehension with a relocation maneuver, is essentially diagnostic for anterior shoulder instability.120

Radiographic Evaluation of Instability

Radiographic evaluation may include plain radiographs, magnetic resonance (MR) imaging, and CT scans. An appreciation for concomitant glenoid fractures, large Hill-Sachs lesions, and other bony abnormalities are helpful in determining whether arthroscopic or open stabilization is the appropriate surgical approach. Determining coexisting pathology (i.e., rotator cuff tears), the degree of capsular laxity, and the extent of labral pathology is also helpful in selecting the appropriate surgical procedure. Plain Radiography

Anteroposterior and axillary radiographs are requisite to document glenohumeral reduction and to rule out fractures. The West Point axillary view*04is useful to image the anterior glenoid, and the Stryker notch view50 is useful to evaluate the posterior humeral head (i.e., Hill-Sachs lesions). The anteroposterior radiograph in internal rotation is also effective in evaluating the Hill-Sachs lesion. Magnetic Resonance Imaging

MR imaging is of some value in evaluating patients with traumatic anterior instability. Questions remain about the value of MR arthrography. Some studies have demonstrated MR arthrography to be more than 90% sensitive and specific in detecting inferior labral ligamentous lesions.46,59 This is superior to plain MR imaging or CT arthrography. MR imaging is especially helpful in evaluating patients more than 40 years of age because of the frequency of concomitant rotator cuff pathology.

34

COLE & WARNER

Computed Tomography Computed tomography is an effective tool to demonstrate the size of associated glenoid fractures and impression fractures of the humeral head. CT is also useful to determine the orientation of the glenoid, including hypoplasia and version abnormalities. CT arthrography can demonstrate soft-tissue pathology, such as capsular or labral detachment and excessive capsular redundancy.67,113

Examination Under Anesthesia Limitations of the history taking and physical examination caused by muscle guarding are offset by information learned from the examination under anesthesia (EUA). The predominant direction of the instability and lesser components of the instability are determined by EUA. Most often, EUA supports the diagnosis established through history taking and physical examination. Before the EUA is performed, the humeral head must be centered on the glenoid to avoid mistaking a reduction for a subluxation in the opposite direction. Stability is tested in all three directions (i.e., anterior, posterior, and inferior) using several arm positions of abduction and placing different portions of the capsule on tension?*General anesthesia and muscle relaxation is important to allow for side-to-side comparisons. Testing the shoulder in adduction, 45" and 90" of abduction, and internal and external rotation evaluates the integrity of the ligaments to direct surgical treatment. Generalized ligamentous laxity, or a significant inferior component as demonstrated by an increased sulcus sign in external rotation, indicates the need to address both capsular laxity and, possibly, the rotator interval. A high correlation exists between the findings on EUA and the findings at the time of stabilization surgery.22

Arthroscopic Evaluation Additional pathoanatomic information about the instability is gained from a routine diagnostic arthroscopic examination, even if a surgeon intends to perform an open stabilization. Initial arthroscopic examination should consist of a systematic review of the glenohumeral joint to detect coexisting pathology. Common findings associated with traumatic anterior instability include anterior labral detachment, capsular injury, or articular cartilage damage to the posterior humeral head. In order of decreasing frequency, one should expect to find anterior

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

35

glenoid labral tears, ventral capsule insufficiency, Hill-Sachs lesions, 88 glenohumeral ligament insufficiency, and rotator-cuff The size and quality of the anterior band of the IGHL is critical to patient selection. Normally, the anterior band should develop significant tension and migrate superiorly with progressive shoulder abduction and external rotation.90Probing and grasping the anterior casuloligamentous structures and viewing them from the anterior portal is helpful to further determine their integrity. Pagnani and Warren9* described the "drive-through' sign as an arthroscopic indication for significant glenohumeral laxity. While viewing from posteriorly with the arthroscope with the arm in adduction and neutral rotation, the ability to move the arthroscopic anteriorly through the glenohumeral joint and sweep down into the axillary pouch with little or no resistance implies significant capsular laxity. Information gained from the arthroscopy can confirm the suspected diagnosis and determine whether a patient is a suitable candidate for arthroscopic stabilization.

PROCEDURE SELECTION Patient Preferences Except for first-time dislocators who elect to have primary Bankart repair in the acute ~ e t t i n gall , ~ patients who place a premium on stability should probably be indicated for open stabilization. In the absence of absolute contraindications to arthroscopic stabilization and despite conflicting reports of motion loss following open and arthroscopic stabilization, patients who place a premium on maintaining external rotation may benefit more from arthroscopic stabilization. Similarly, patients who have significant aversions to the perioperative morbidity associated with an open-stabilization procedure in the absence of absolute contraindications are candidates for arthroscopic stabilization.

Surgeon Preferences Despite the emergence of innovative instrumentation, fixation devices, and techniques for arthroscopically repairing the pathology associated with traumatic anterior shoulder instability, a relatively steep learning curve exists for most methods. Surgeons inexperienced in arthroscopic stabilization techniques should be prepared to convert to a traditional open technique to reduce the risk for recurrence and complications. Fortunately, educational initiatives sponsored by the American

36

COLE & WARNER

Academy of Orthopedic Surgeons and the Arthroscopy Association of North America have helped interested surgeons to efficiently and reliably acquire the necessary experience and skill to optimize outcomes following arthroscopic stabilization of the shoulder. Pathology-Based Procedure Selection

The ability to make absolute decisions based on the pathology identified during the preoperative evaluation is ideally suited for the ends of the pathologic spectrum. In other words, some patients are considered ideal candidates for arthroscopic stabilization, and some patients are considered ideal candidates for open-stabilization techniques. Ideal Indications for Arthroscopic Stabilization

Interest in the application of arthroscopic stabilization as the primary therapy for athletes with acute and subacute anterior instability is increasing. Specifically a high-performance, overhead-throwing athlete, such as a baseball player, quarterback, or tennis player may be an excellent candidate because of seasonal requirements and the risk for loss in external rotation, but the ideal candidates are noncontact athletes or more sedentary individuals with traumatic anterior instability with discrete detachment pathology (i.e., Bankart lesion), a robust, well-developed IGHL without significant capsular laxity, intraligamentous injury, or concomitant intra-articular pathology. Ideal Indications for Open Stabilization

Contact athletes and individuals with large Hill-Sachs lesions and marked anterior laxity with attenuated or poor-quality anterior ligamentous structures with or without intrasubstance injury are considered optimal candidates for open stabilization techniques. Ligamentous laxity, atraumatic instability, a bony Bankart lesion, a rotator cuff teag and the absence of a Bankart lesion are also relative indications to perform open stabilization. Thermal Capsulorrhaphy: Extending the Indications for Arthroscopic Stabilization

The Bankart lesion is what can be detected macroscopically at the time of arthroscopy. Often unappreciated is the degree of capsular plastic deformation. Because of newer techniques, including the thermal treat-

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

37

ment of capsular tissue to reduce capsular laxity, capsular laxity is now treated arthroscopically at the time of Bankart repair. To date, insufficient clinical information is available to unequivocally recommend these procedures as a routine adjunct to arthroscopic 51, 54, Io3, When applying techniques, such as radiofrequency capsular shrinkage or laser-assisted capsulorrhapy, respect for the initial healing and revascularization phase must be observed. General recommendations include stabilizing the Bankart lesion first, followed by thermal reduction of the capsular laxity while avoiding any thermal treatment near the arthroscopic suture line to prevent weakening of this area. Rehabilitation, including the extremes of rotation, is delayed for at least the first 3 weeks to avoid disrupting the thermally weakened capsule. Specific rehabilitation protocols are determined by the pathology treated at the time of arthroscopy. Closure of the Rotator Interval

A high index of suspicion must exist for a rotator interval defect if a patient demonstrates a large inferior component to his or her anteroinferior instability during EUA, especially with the arm in adduction and external rotation. Arthroscopically, a rotator interval defect may be difficult to appreciate because the absent or attenuated capsule within the rotator interval muscular region is difficult to differentiate from the joint side of the subscapularis or supraspinatus muscles,u but capsular redundancy or fraying within the muscular interval as visualized from the posterior arthroscopic portal provides clues to the integrity of the capsule in addition to the findings from EUA. Several investigators have advised surgeons to close this interval during open repair of glenohumeral in~tability.~~, 83, lo8 Techniques for arthroscopic closure of the rotator interval were reported by Gartsman and associates39and 0 t h e ~ s . lIndependent ~~ of whether rotator interval closure is performed during open or arthroscopic stabilization, caution must be used to position the arm in at least 30" to 45" of external rotation to avoid a permanent loss of external rotation.

TREATMENT ALGORITHM

The data collected during patient evaluation, including the findings on radiographic evaluation, EUA, and the pathology identified at the time of arthroscopy, are critical to making the most informed decisions when treating patients with recurrent traumatic anterior instability. An algorithm based on the findings described by the literature is recom-

38

COLE & WARNER

mended to select patients for arthroscopic or open shoulder stabilization (Fig. 1). To summarize, radiographic evaluation using MR imaging or CT scan of the shoulder may help to determine preoperatively the condition of the labrum and capsule. For example, a discrete Bankart lesion (Fig. 2 ) could be differentiated from capsular redundancy (Fig. 3) with these tests. Patients with a discrete Bankart lesion are better candidates for arthroscopic stabilization, whereas patients with obvious capsular redundancy or without a Bankart lesion are better candidates for open stabilization. The presence or size of the Hill-Sachs lesion is an area in which surgeon judgment often prevails. Information learned from the EUA, with findings graded as described by Altchek et al,' determines the predominant direction of the instability and lesser components of the instability. Patients demonstrating pure 2 or 3 + anterior translation compared with the contralateral shoulder (e.g./ subluxation over the glenoid rim with spontaneous reduction or frank dislocation over the glenoid rim without spontaneous reduction) are generally considered good candidates for arthroscopic stabilization. Patients with a 2 + or greater sulcus sign compared with

+

Pathology-Based Procedure Selection MRllCT Scan

$-\ Arthroscopic Findingsb-4

' 0

Examination Under Anesthesia

Arthroscopic Stabilization

Open Stabilization

Unidirectional

Bidirectional

MRI/CT evidence of Bankart

MRVCT evidence of laxity

Robust AB, IGHL

Poorly defined AB, IGHL

Minimal capsular laxity

Patulous capsule

Minimal articular involvement

BonyBankart

Figure 1. Algorithm used to determine the procedure at the time of surgery. AB band; IGHL = inferior glenohumeral ligament.

=

anterior

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

39

Figure 2. Axial, gadolinium-enhanced MR image demonstrating a discrete Bankart lesion with periosteal stripping of the anterior scapular neck.

Figure 3. CT arthrogram of the shoulder showing capsular laxity in the abscence of a Bankart lesion.

40

COLE & WARNER

the contralateral shoulder (i.e., an acromiohumeral distance of 1-2 cm) in addition to their anterior translation are usually considered better candidates for open stabilization. Routine diagnostic arthroscopy to evaluate the articular surfaces should evaluate the status and integrity of the biceps complex, labrum, rotator cuff, capsule, and glenohumeral ligaments. Anatomic lesions, such as a detached anteroinferior glenoid labrum; a Hill-Sachs lesion; excessive capsular redundancy; or subtle signs of instability, such as labral fraying or wear, are determined. Findings of a detached anteroinferior glenoid labrum or a discrete Bankart lesion (Fig. 4) without significant fraying or degeneration with adequate tissue quality can more easily be repaired arthroscopically. Alternatively, patients with excessively redundant capsules or significant capsular laxity or rupture with or without a Bankart lesion (Fig. 5) are better candidates for open stabilization. Performing the drive-through test after arthroscopic Bankart repair is helpful to determine whether residual capsular laxity should be addressed at the time of stabilization by thermal or open means. SUMMARY

After more than 15 years of experience, arthroscopic shoulder stabilization is becoming less controversial. Historically, recurrence rates following arthroscopic stabilization have been higher than with open stabi-

Figure 4. Arthroscopic evaluation of a discrete Bankart lesion treated with arthroscopic stabilization using a bioabsorbable tack (same patient as Fig. 2).

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

41

Figure 5. Arthroscopic evaluation of a patulous capsule treated with selective open anterior capsular shift (same patient as Fig. 3).

lization. Although a negligible advantage may exist in terms of expedited postoperative rehabilitation and improved postoperative recovery of motion, critics suggest that its use in contact athletes be limited. The indications for arthroscopic stabilization are expanding, in part, because of improved understanding of the pathophysiology of shoulder instability. Understanding the mechanism of recurrent instability following arthroscopic stabilization offers clues to how physicians can prevent unsatisfactory results in the future. With newer instrumentation and the ability to thermally treat capsular tissue, coexisting pathology, such as capsular plastic deformation, rotator interval lesions, and unrecognized intra-articular pathology, can now be addressed arthroscopically. The judicious use of these techniques is warranted until longterm study results become available. Ideal patients for arthroscopic Bankart repair have a discrete Bankart lesion; a robust, well-developed IGHL; no significant capsular laxity or intraligamentous injury; and an absence of concomitant intra-articular pathology. Additional findings on MR imaging or CT evidence of a discrete labral lesion and pure unidirectional anterior instability during EUA are also good prognostic indicators for arthroscopic Bankart repair. Arthroscopic criteria that render patients less appropriate for an arthroscopic repair include capsular injury, capsular laxity, a bony Bankart lesion, glenohumeral arthritis, and a rotator cuff tear. The authors’ believe that either absent or patulous, poorly developed glenohumeral ligaments represent a poor prognostic indicator for a successful outcome

42

COLE & WARNER

following standard arthroscopic Bankart repair. Individuals with poorquality tissue are more predictably managed using open capsulorrhaphy. Patients with pathologic ligamentous laxity in the absence of a Bankart lesion or any apparent intraligamentous injury to the IGHL are also good candidates for treatment with an open capsulorrhaphy. Findings determined from a thorough physical examination, EUA, and the pathology appreciated during diagnostic arthroscopy help to appropriately choose the surgical procedure that effectively addresses pathology in patients who present with recurrent traumatic anterior instability. Patient preferences and surgical experience are important determinants of procedure selection, and current arthroscopic techniques lack the versatility to uniformly address the entire spectrum of pathology that may be associated with traumatic anterior shoulder instability. Surgeons should always be prepared to convert to an open-stabilization technique if the arthroscopic technique is deficient in addressing all pathology identified at the time of surgery.

References 1. Altchek D, Warren R, Skyhar M, et al: T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am 73:105-112, 1991 2. Altchek D, Warren R, Wickiewicz T Arthroscopic capsular shift: A retrospective analysis of 21 patients. Arthroscopy 8:411-412, 1992 3. Arciero R, St. Pierre F: Acute shoulder dislocation: Indications and techniques for operative management. Clinics Sports Med 14:937-953, 1995 4. Arciero R, Taylor D, Snyder R, et al: Arthroscopic bioabsorbable tack stabilization of initial anterior shoulder dislocations: A preliminary report. Arthroscopy 11:410-417, 1995 5. Arciero R, Wheeler J, Ryan J, et al: Arthroscopic Bankart repair vs. nonoperative treatment for acute, initial anterior dislocation of the shoulder. Am J Sports Med 22:589-594, 1994 6. Bach B, Warren R, Fronek J: Disruption of the lateral capsule of the shoulder: A cause of recurrent dislocation. J Bone Joint Surg Br 70:274-276, 1988 7. Bacilla P, Field L, Savoie F: Arthroscopic Bankart repair in a high demand patient population. Arthroscopy 13:51-60, 1997 8. Baker C, Uribe J, Whitman C: Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 18:2.528, 1990 9. Bankart A: The pathology and treatment of recurrent dislocation of the shoulderjoint. Br J Surg 26:23-29, 1938 10. Barber F, Click S, Weidmeman C: Arthroscopic or open Bankart procedures: What are the costs? Arthroscopy 14671474, 1998 11. Belzer J, Snyder J: Arthroscopic capsulorrhaphy for traumatic anterior shoulder instability using suture anchors and nonabsorbable suture. Arthroscopy 11:359, 1995 12. Benedetto K, Glotzer W Arthroscopic Bankart procedure by suture technique: Indications, technique, and results. Arthroscopy 8:111-115, 1992 13. Bigliani L, Flatow E, Kelkar R, et al: The effect of anterior capsular tightening on shoulder kinematics and contact. J Shoulder Elbow Surg 3(suppl):65,1994 14. Bigliani L, Kurzweil P, Schwartzbach C, et al: Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med 22578-584, 1994

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

43

15. Bigliani L, Pollock R, Soslowsky L, et al: Tensile properties of the inferior glenohumeral ligament. J Orthop Res 10:187-197, 1992 16. Bigliani L, Weinstein D, Glasgow M, et al: Glenohumeral arthroplasty for arthritis after instability surgery. J Shoulder Elbow Surg 4:87-94, 1995 17. Burger R, Shengel D, Bonatus T, et al: Arthroscopic staple capsulorrhaphy for recurrent shoulder instability. Orthop Trans 14973, 1990 18. Calandra J, Baker C, Uribe J: The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations. Arthroscopy 53254-257, 1989 19. Caspari R Arthroscopic reconstruction for anterior shoulder instability. Tech Orthop 3:5946, 1988 20. Casperi R, Savoie F: Arthroscopic reconstruction of the shoulder: The Bankart repair. In J McGinty (ed): Operative Arthroscopy. New York, Raven Press, 1991, p p 507-516 21. Cofield R, Irving J: Evaluation and classification of shoulder instability: With special reference to examination under anesthesia. Clin Orthop 223:3243, 1987 22. Cofield R, Nessler J, Weinstabl R Diagnosis of shoulder instability by examination under anesthesia. Clin Orthop 291:45-53, 1993 23. Cole B, Rodeo S, OBrien S, et al: The developmental anatomy of the rotator interval capsule and the rotator interval defect: An anatomic and histologic analysis of fetal and adult cadaver specimens with clinical implications. Presented at the American Orthopaedic Society for Sports Medicine Specialty Day. San Francisco, February 16, 1997 24. Cole B, Warner J: Anatomy, biomechanics, and pathophysiology of glenohumeral instability. In Iannotti J, Williams G (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelpha, Lippincott-Raven, 1999, pp 207-232 25. Cole B, Warner J, L‘Insalata J, et al: Prospectively determined arthroscopic versus open shoulder stabilization: 2 to 6 year follow up. J Shoulder Elbow Surg 7313, 1998 26. Conolly J: Humeral head defects associated with shoulder dislocation: The diagnostic and surgical significance. Instr Course Lect 21:42-52, 1972 27. Cooper D, Arnoczky S, OBrien S, et al: Anatomy, histology, and vascularity of the glenoid labrum: An anatomical study. J Bone Joint Surg Am 7446-52, 1992 28. Coughlin L, Rubinovich M, Johansson J, et al: Arthroscopic staple capsulorrhaphy for anterior shoulder instability. Am J Sports Med 20:253-256, 1992 29. Detrisac D: Arthroscopic staple capsulorrhaphy for traumatic anterior instability. In McGinty J (ed): Operative Arthroscopy. New York, Raven Press, 1991, pp 507-516 30. Deutsch A, Protomastro P, Barber J, et al: The biomechanical effects of thermal capsulorrhaphy on the kinematic properties of the glenohumeral joint. Presented at the American Shoulder and Elbow Surgeon’s Specialty Day. Anaheim, CA, 1999, p 11 31. Dickson J, Devas M: Bankart’s operation for recurrent dislocation of the shoulder. J Bone Joint Surg Br 39:114-119, 1957 32. Duncan R, Savoie FI: Arthroscopic inferior capsular shift for multidirectional instability of the shoulder: A preliminary report. Arthroscopy 9:24-27, 1993 33. DuToit G, Roux D: Recurrent dislocation of the shoulder. J Bone Joint Surg Am 38:1-12, 1956 34. Edwards D, Howy G, Saies A, et al: Adverse reactions to an absorbable shoulder fixation device. J Shoulder Elbow Surg 3:230-233, 1994 35. Ekelund A: Cartilage injuries in the shoulder joint caused by migration of suture anchors or mini screw. J Shoulder Elbow Surg 7:537-539, 1998 36. Field L, Savoie F, Griffith P: A comparison of open and arthroscopic Bankart repair [abstract]: J Shoulder Elbow Surg 8:195, 1999 37. Field LD, Warren RF, OBrien SJ, et al: Isolated closure of rotator interval defects for shoulder instability. Am J Sports Med 23:557-563, 1995 38. Foster C: Arthroscopic shoulder reconstruction for instability. Orthop Trans 18:192, 1994 39. Gartsman G, Taverna E, Hammerman S: Arthroscopic rotator interval repair in glenohumeral instability: Description of an operative approach. Arthroscopy 15:33&332, 1999 40. Geiger D, Hurley J, Tovey J, et al: Results of arthroscopic versus open Bankart suture repair. Orthop Trans 17973, 1993

44

COLE &WARNER

41. Gerber C Chronic, locked anterior and posterior dislocations. In Warner J, Iannotti J, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, Lippincott-Raven, 1997, pp 99-113 42. Gerber C, Lambert S Allograft reconstruction of segmental defects of the humeral head for the treatment of chronic locked posterior dislocation of the shoulder. J Bone Joint Surg Am 78:37&382, 1996 43. Goldberg 8, Nirschl R, McConnell J, et al: Arthroscopic transglenoid suture capsulolabra1 repairs: Preliminary results. Am J Sports Med 2k656-665, 1993 44. Grana W, Buckley P, Yates C: Arthroscopic Bankart suture repair. Am J Sports Med 21:348-353, 1993 45. Green M, Christensen K Arthroscopic versus open Bankart procedures: A comparison of early morbidity and complications. Arthroscopy 9:371-374,1993 46. Green M, Christensen K Magnetic resonance imaging of the glenoid labrum: MR imaging of 88 arthroscopically confirmed cases. Am J Sports Med 22:493498, 1994 47. Green M, Christensen K Arthroscopic Bankart procedure: Two- to five-year followup with clinical correlation to severity of glenoid labral lesion. Am J Sports Med 23:276-281, 1995 48. Gross R Arthroscopic shoulder capsulorrhaphy: Does it work? Am J Sports Med 17495-500, 1989 49. Guanche C, Quick D, Sodergren K, et al: Arthroscopic versus open reconstruction of the shoulder with isolated Bankart lesions. Am J Sports Med 243144-148, 1996 50. Hall R, Isaac F, Booth C: Dislocations of the shoulder with special reference to accompanying small fractures. J Bone Joint Surg Am 41:489-494, 1959 51. Hardy E Thabit G, Fanton G, et al: Arthroscopic management of recurrent anterior shoulder dislocation by combining a labrum suture with antero-inferior holmium: YAG laser capsular shrinkage. Orthopedics 25:91-93, 1996 52. Harryman DT, Sidles JA, Harris SL, et al: The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 74:53-66, 1992 53. Hawkins R Arthroscopic stapling repair for shoulder instability: A retrospective study of 50 cases. Arthroscopy 5:122-128, 1989 54. Hayashi K, Massa K, Thabit G, et al: Histologic evaluation of the glenohumeral joint capsule after the laser-assisted capsular shift procedure for glenohumeral instability. Am J Sports Med 27:162-167, 1999 55. Hinterman B, Gachter A: Arthroscopic findings after shoulder dislocation. Am J Sports Med 23:545-551, 1996 56. Hoffman F, Reif G: Arthroscopic shoulder stabilisation using Mitek anchors. Knee Surg Sports Traumatol Arthrosoc 3:5&54, 1995 57. Hovelius L: Anterior dislocation of the shoulder in teen-agers and young adults: Five-year prognosis. J Bone Joint Surg Am 69:39%399, 1987 58. Hsu HC, Wu JJ, Lo WH, et al: Rotator interval tear: a case report. Chung Hua I Hsueh Tsa Chih (Taipei) 50258-260, 1992 59. Iannotti J, Zlatkin M, Esterhai J, et al: Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value. J Bone Joint Surg Am 73:17-29, 1991 60. Ikeda H: Rotator interval lesion: I. Clinical study. J Jpn Orthop Assoc 60:1261-1274, 1986 61. Janevic J, Craig E, Hsu KC, et al: Biomechanics of repair of anterior instability. Trans Orthop Res SOC17495, 1992 62. Jobe F, Giangarra C, Kvitne R, et al: Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 19:42%434, 1991 63. Johnson D, Warner J: Osteochondritis dissecans of the humeral head: Treatment with a matched osteochondral allograft. J Shoulder Elbow Surg 6160-163, 1997 64. Johnson L: Techniques of anterior glenohumeral ligament repair. In Johnson L (ed): Arthroscopic Surgery: Principles and Practice, ed 3, vol2. St. Louis, CV Mosby, 1986, pp 1405-1420 65. Johnson L: Diagnostic and Surgical Arthroscopy of the Shoulder. p. 276-364. St. Louis, Mosby-Year Book, 1993, pp 27&364 66. Kempf J, Nerisson D, Bonnomet F, et al: Recurrent anterior instability of the shoulder

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

45

treated by arthroscopic staple capsulorrhaphy. J Shoulder Elbow Surg 3(suppl):33, 1994 67. Kinnard P, Tricoire J, Levesque R, et al: Assessment of the unstable shoulder by computed arthrography: A preliminary report. Am J Sports Med 11:157-159, 1983 68. Landsiedl F: Arthroscopic therapy of recurrent anterior luxation of the shoulder by capsular repair. Arthroscopy 8296304, 1992 69. Lane J, Sachs R, Riehl B: Arthroscopic staple capsulorrhaphy: A long-term follow-up. Arthroscopy 9:190-194, 1993 70. Laurencin C, Stephens S, Warren R, et al: Arthroscopic Bankart repair using a degradable tack. Clin Orthop 332132-137, 1996 71. Lazarus M, Sidles J, Harryman DI, et al: Effect of a chondral-labral defect on glenoid concavity and glenohumeral stability. J Bone Joint Surg Am 78394-102, 1996 72. Levine W, Richmond J, Danaldson W Use of the suture anchor in open Bankart reconstruction: A follow-up report. Am J Sports Med 22:723-726, 1994 73. Lippitt S, Vanderhooft J, Harris S, et al: Glenohumeral stability from concavitycompression: A quantitative analysis. J Shoulder Elbow Surg 227-35, 1993 74. Luckey C: Recurrent dislocation of the shoulder: Modified Bankart capsulorrhaphy. Am J Surg 77220-222, 1949 75. Maki N: Arthroscopic stabilization suture technique. Op Tech Orthop 1:180-183, 1991 76. Manta J, Organ S, Nirschl R, et al: Arthroscopic transglenoid suture capsulolabral repair. Am J Sports Med 25:614-618, 1997 77. Marcacci M, Zaffagnini S, Petitto A, et al: Arthroscopic management of recurrent anterior dislocation of the shoulder: Analysis of technical modifications on the Caspari procedure. Arthroscopy 12:144-149, 1996 78. Mathews L, Vetter W, Oweida S, et al: Arthroscopic staple capsulorrhaphy for recurrent anterior shoulder instability. Arthroscopy 4:106111, 1988 79. McLaughlin H: Posterior dislocation of the shoulder. J Bone Joint Surg Am 34:xx, 1952 80. Mologne T, Lapoint J, Morin W, et al: Arthroscopic anterior labral reconstruction using a transglenoid suture technique. Am J Sports Med 24268-274, 1996 81. Morgan C. Arthroscopic transglenoid Bankart suture repair. Op Tech Orthop 1:171179, 1991 82. Morgan C, Bodenstab A Arthroscopic Bankart suture repair: Technique and early results. Arthroscopy 3:111-122, 1987 83. Neer CS, Foster C Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg Am 62:xx, 1980 84. Neer CS, Satterlee CC, Dalsey RM, et al: The anatomy and potential effects of contracture of the coracohumeral ligament. Clin Orthop 223:182-185, 1992 85. Nevaiser T The anterior labroligamentous periosteal sleeve avulsion lesion: A cause of anterior instability of the shoulder. Arthroscopy 9:17-21, 1992 86. Nobuhara K: The rotator interval lesion. In Wayne J, Burkhead Z (ed): Rotator Cuff Disorders. Baltimore, Williams & Wilkins, 1996, pp 182-192 87. Nobuhara K, Ikeda H Rotator interval lesion. Clin Orthop 223:44-50, 1987 88. Norlin R Intraarticular pathology in acute, first-time anterior shoulder dislocation: An arthroscopic study. Arthroscopy 9:546-549, 1993 89. Oberlander M, Morgan 8, Visotsky J: The BAGL lesion: A new varient of anterior shoulder instability. Arthroscopy 12627-633, 1996 90. OBrien S, Schwartz R, Warren R, et al: Capsular restraints to anterior-posterior motion of the abducted shoulder: A biomechanical study. J Shoulder Elbow Surg 4298-308, 1995 91. Pagnani M, Deng XH, Warren R, et al: Role of the long head of the biceps brachii in glenohumeral stability: A biomechanical study in cadavera. J Shoulder Elbow Surg 5:255-262, 1996 92. Pagnani M, Warren R: Arthroscopic shoulder stabilization. Op Tech Sports Med 1:276-284, 1993 93. Pagnani M, Warren R, Altchek D, et al: Arthroscopic shoulder stabilization using transglenoid sutures: A four-year minimum follow-up. Am J Sports Med 24xx, 1996 94. Pagnani M, Xiang-Hua D, Warren R, et al: Effect of lesions of the superior portion of

46

COLE &WARNER

the glenoid labrum on glenohumeral translation. J Bone Joint Surg Am 7710031010, 1995 95. Pavlov H, Warren R, Weiss C, et al: The roentgenographic evaluation of certain surgical conditions. Clin Orthop 184:317-321, 1985 96. Perthes G: Uber operation bei habitueller schulterluxation. Deutsche Zeitschr Chir 85:199-227, 1906 97. Pollock R, Owens J, Nicholson G, et al: The anterior inferior capsular shift procedure for anterior glenohumeral instability: Technique and long-term results. Orthop Trans 171109, 1993-1994 98. Protzman R Anterior instability of the shoulder. J Bone Joint Surg Am 62:909-918, 1980 99. Rao J, Tovey J, Zoppi A, et al! Comparison of arthroscopic capsulorrhaphy for anterior shoulder instability: Stapling versus suturing. Orthop Trans 17972-973, 1993 100. Reider 8, Ingles A: The Bankart procedure modified by the use of prolene pull-out sutures. J Bone Joint Surg Br 76628429, 1982 101. Resch H, Golser K, Spemer G: Die arthroskopische Labrumrefixation mit resorbierbarbaren Staples. Arthskopie 5239, 1992 102. Resch H, Povacz P, Wambacher M, et al: Arthroscopic extra-articular Bankart repair for the treatment of recurrent anterior shoulder dislocation. Arthroscopy 13:188-200, 1997 103. Rodeo S, Suzuki K, Hannafin J: Analysis of collagen and elastic fibers in shoulder capsule in patients with shoulder instability. Am J Sports Med 26:624-643, 1998 104. Rokous J, Feagin J, Abbott H: Modified axillary roentgenogram: A useful adjunct in the diagnosis of recurrent instability of the shoulder. Clin Orthop 82:84-86, 1972 105. Rose D: Arthroscopic suture capsulorrhaphy for anterior shoulder instability. Orthop Trans 14597, 1990 106. Rowe C, Pate1 D, Southmayd W The Bankart procedure: A long-term end-result study. J Bone Joint Surg Am 6O:l-16, 1978 107. Rowe C, Sakellarides H: Factors related to recurrences of anterior dislocations of the shoulder. Clin Orthop 20:4048, 1961 108. Rowe C, Zarins B: Recurrent transient subluxation of the shoulder. J Bone Joint Surg Am 63:8634372, 1981 109. Rowe C, Zarins B, Ciullo J: Recurrent anterior dislocation of the shoulder after surgical repair. J Bone Joint Surg Am 66:159-168, 1984 110. Rubenstein D, Jobe F, Glousman R: Anterior capsulolabral reconstruction of the shoulder in athletes. J Shoulder Elbow Surg 1:229-237, 1992 111. Savoie F, Miller C, Field L: Arthroscopic reconstruction of traumatic anterior instability of the shoulder: The Caspari technique. Arthroscopy 13:201-209, 1997 112. Selecky M, Vangsness C, Liao WL, et al: The effects of laser-induced collagen shortening on the biomechanical properties of the inferior glenohumeral ligament complex. Am J Sports Med 27168-172, 1999 113. Singson R, Feldman F, Bigliani L: CT arthrographic patterns in recurrent glenohumeral instability. Am J Roentgen01 149:749-753, 1987 114. Sisto D, Cook D: Intraoperative decision making in the treatment of shoulder instability. Arthroscopy 14:389-394, 1998 115. Small N: Complications in arthroscopy: The knee and other joints. Committee on Complications of the Arthroscopy of North America. Arthroscopy 2:253-258, 1986 116. Snyder S: Shoulder Arthroscopy. New York, McGraw-Hill, 1994, pp 179-214 117. Snyder S, Karzel R, DelPizzo W, et al: SLAP lesions of the shoulder. Arthroscopy 63274-279, 1990 118. Snyder S, Strafford 8: Arthroscopic management of instability of the shoulder. Orthopedics 16:993, 1993 119. Speer K, Deng X, Torzilli P, et al: A biomechanical evaluation of the Bankart lesion. Trans Orthop Res SOC39:315, 1993 120. Speer K, Hannafin J, Altchek D, et al: An evaluation of the shoulder relocation test. Am J Sports Med 22:177-183, 1994 121. Speer K, Warren R Arthroscopic shoulder stabilization: A role for biodegradable materials. Clin Orthop 291:67-74, 1993

ARTHROSCOPIC VERSUS OPEN BANKART REPAIR FOR SHOULDER INSTABILITY

47

122. Speer K, Warren R, Pagnani M, et al: An arthroscopic technique for anterior stabilization of the shoulder with a bioabsorbable tack. J Bone Joint Surg Am 78:1801-1807, 1996 123. Steinbeck J, Jerosch J: Arthroscopic transglenoid stabilization versus open anchor suturing in traumatic anterior instability of the shoulder. Am J Sports Med 26:373378, 1998 124. Steinmann S, Bigliani L, McIlveen S: Glenoid fractures associated with recurrent anterior dislocation of the shoulder. Presented at the 57th Annual Meeting of the American Academy of Orthopaedic Surgeons. New Orleans, 1990, p 173 125. Symeonides P: The significance of the subscapularis muscle in the pathogenesis of recurrent anterior dislocation of the shoulder. J Bone Joint Surg Br 54476-483, 1972 126. Tamai K, Higashi A, Tanabe T, et al: Recurrences after the open Bankart repair: A potential risk with use of suture anchors. J Shoulder Elbow Surg 8:3741, 1999 127. Taylor D, Arciero R Pathologic changes associated with shoulder dislocations. Am J Sports Med 25:306-311, 1997 128. Thomas S, Matsen F I An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability. J Bone Joint Surg Am 71:506-513, 1989 129. Ticker J, Bigliani L, Soslowsky L, et al: Inferior glenohumeral ligament: Geometric and strain-rate dependent properties. J Shoulder Elbow Surg 5:269-279, 1996 130. Ticker J, Lippe R, Barkin D, et al: Infected suture anchors in the shoulder. Arthroscopy 12~613-615,1996 131. Torchia M, Caspari R, Asselmeier M, et al: Arthroscopic transglenoid suture repair: 2 to 8 year results in 150 shoulders. Arthroscopy 13:609-619, 1997 132. Townley C: The capsular mechanism in recurrent dislocation of the shoulder. J Bone Joint Surg Am 32:370-380, 1950 133. Treacy S, Field L, Savoie F: Rotator interval capsule closure: An arthroscopic technique. Arthroscopy 13:103-106, 1997 134. Viek P, Ben B: The Bankart shoulder reconstruction: The use of pull-out wires and other details. J Bone Joint Surg Am 41:236-242, 1959 135. Walch G, Boileau P, Levigne C, et al: Arthroscopic stabilization for recurrent anterior shoulder dislocation: Result of 59 cases. Arthroscopy 11:173-179, 1995 136. Warner J, Beim G: Combined Bankart and HAGL lesion associated with anterior shoulder instability. Arthroscopy 13:749-752, 1997 137. Warner J, Miller M, Marks P, et al: Arthroscopic Bankart repair with the Suretac device: Part I. Clinical observations. Arthroscopy 11:2-13, 1995 138. Warner J, Pagnani M, Warren R, et al: Arthroscopic Bankart repair utilizing a cannulated absorbable fixation device. Orthop Trans 15:761-762, 1991 139. Warren R, Kornblatt I, Marchand R Static factors affecting posterior shoulder stability. Orthop Trans 8:89, 1984 140. Weber B, Simpson L, Hardegger F, et al: Rotational humeral osteotomy for recurrent anterior dislocation of the shoulder associated with a large Hill-Sachs lesion. J Bone Joint Surg Am 66:1443-1450, 1984 141. Weber S A prospective evaluation comparing arthroscopic and open treatment in the management of recurrent anterior glenohumeral dislocation. Orthop Trans 15:763, 1991 142. Wheeler J, Ryan J, Arciero R, et al: Arthroscopic versus nonoperative treatment of acute shoulder dislocation. Arthroscopy 5:213-217, 1989 143. Wiley A Arthroscopy for shoulder instability and a technique for arthroscopic repair. Arthroscopy 425-30, 1988 144. Wilson F, Adams G, Hile L, et al: Arthroscopic treatment of the recurrent dislocating shoulder. Orthop Trans 17973, 1993 145. Wirth M, Blatter G, Rockwood C: The capsular imbrication procedure for recurrent anterior instability of the shoulder. J Bone Joint Surg Am 78:246-259, 1996 146. Wolf E: Arthroscopic capsulolabral repair using suture anchors. Orthop Clin North Am 2459-69, 1993 147. Wolf E, Cheng J, Dickson K Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 11:600407, 1995

48

COLE & WARNER

148. Wolin P: Arthroscopic glenoid labrum suture repair. Orthop Trans 14:597, 1990 149. Youssef J, Carr C, Walther C, et al: Arthroscopic Bankart suture repair for recurrent traumatic unidirectional anterior shoulder dislocations. Arthroscopy 11:561-563, 1995 150. Zuckerman J, Matsen FI: Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg Am 66175-180, 1984

Address reprint requests to Brian J. Cole, MD 1725 West Harrison Suite 1063 Chicago, IL 60612