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Results of Arthroscopic Capsulolabral Repair: Bankart Lesion Versus Anterior Labroligamentous Periosteal Sleeve Avulsion Lesion
Results of Arthroscopic Capsulolabral Repair: Bankart Lesion Versus Anterior Labroligamentous Periosteal Sleeve Avulsion Lesion Mehmet Ozbaydar, M.D., Bassem Elhassan, M.D., David Diller, B.A., Daniel Massimini, B.S., Laurence D. Higgins, M.D., and Jon J. P. Warner, M.D.
Purpose: The purpose of this study was to evaluate the results of arthroscopic capsulolabral repair for traumatic anterior shoulder instability and to compare the outcome in patients who have Bankart lesions versus those with anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions. Methods: This study included 99 patients (93 shoulders), 72 male and 17 female, with a mean age of 32 years, who underwent arthroscopic Bankart repair for traumatic, recurrent anterior shoulder instability, by use of suture anchors. In 67 shoulders (72%) a discrete Bankart lesion was repaired, and in 26 shoulders (28%) an ALPSA lesion was repaired. The 2 groups were analyzed with regard to the number of preoperative dislocations and number of postoperative recurrences. Results: At a mean follow-up of 47 months (range, 24 to 98 months), recurrence of instability was documented in 10 shoulders (10.7%). Of the shoulders, 5 had Bankart lesions (7.4%) and 5 had ALPSA lesions (19.2%) (P ⫽ .0501). The mean number of dislocations or subluxations before the index surgery was significantly higher in the ALPSA group (mean, 12.3 [range, 2 to 57]) than in the Bankart group (mean, 4.9 [range, 2 to 24]) (P ⬍ .05). However, there were no significant differences in the number of anchors used, incidence of minor glenoid erosion, or incidence of bony Bankart lesions between the groups (P ⬎ .05 for all). Conclusions: Patients with ALPSA lesions present with a higher number of recurrent dislocations than those with discrete Bankart lesions. In addition, the failure rate after arthroscopic capsulolabral repair is higher in the ALPSA group than in the Bankart group. Level of Evidence: Level IV, therapeutic case series. Key Words: Shoulder—Anterior instability—Arthroscopy—Bankart repair— Anterior labroligamentous periosteal sleeve avulsion lesion—Suture anchor.
T
he loss of the stabilizing effects of the bony glenohumeral joint, static capsulolabral tissue, and dynamic muscle compression after shoulder dis-
From the Harvard Shoulder Service (M.O., D.D., D.M., L.D.H., J.J.P.W.); Department of Sports Medicine and Shoulder Service, Harvard Medical School, Brigham and Women’s Hospital (L.D.H.); Department of Orthopaedic Surgery, Harvard Medical School (J.J.P.W.); Massachusetts General Hospital (J.J.P.W.), Boston, Massachusetts; and Mayo Clinic (B.E.), Rochester, Minnesota, U.S.A. The authors report no conflict of interest. Received October 7, 2007; accepted January 23, 2008. Address correspondence and reprint requests to Jon J. P. Warner, M.D., Harvard Shoulder Service, 55 Fruit St, Boston, MA 02114, U.S.A. E-mail: [email protected] © 2008 by the Arthroscopy Association of North America 0749-8063/08/2411-7519$34.00/0 doi:10.1016/j.arthro.2008.01.017
location has been well documented in the literature.1-5 Detachment of the anterior labrum from the glenoid represents disruption of the origin of the inferior glenohumeral ligament, and this has been termed the essential lesion in shoulder instability.3,5,6 In some patients with recurrent anterior glenohumeral instability, the labrum may heal in a medialized position. Neviaser’s 1993 report on this condition was based on his arthroscopic observations that the pathology appeared as an anterior labroligamentous periosteal sleeve avulsion injury, which he termed an ALPSA lesion.7 He identified that in some patients the capsulolabral complex was detached and healed medially on the scapular neck, and this group was distinguished from those patients who had a very clear separation of the labrum and capsule, which represents the classic Bankart lesion.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 11 (November), 2008: pp 1277-1283
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FIGURE 1. Bankart lesion. Apparent detachment of the labrum from the edge of the glenoid is seen.
Although open Bankart repair has been recognized as the gold standard for the treatment of anterior shoulder instability,1,8-13 arthroscopic repair has been shown to be equally effective in many series.8,11,14,15 Moreover, this method of treatment offers advantages of outpatient surgery, better cosmesis, less pain, and more accurate detection of comorbid pathology.16-18 Factors that have a negative prognosis on the success rate of arthroscopic repair include significant bony lesions of the glenoid or humerus, marked capsular laxity or deficiency, and the use of fewer anchors.4,5,8,19-23 The prognostic implication of arthroscopic ALPSA lesion repair has not been previously reported. The purpose of our study was to review our experience with arthroscopic capsulolabral repair in the case of traumatic, recurrent instability and do so in the context of Bankart lesions versus ALPSA lesions. We hypothesized that patients with ALPSA lesions would have a higher recurrence rate after arthroscopic capsulolabral repair for recurrent instability and that this would correlate with a greater incidence of instability episodes before surgery.
subscapularis tear. Bony reconstruction for marked loss of the anterior glenoid was done in 61 patients. We identified a consecutive series of 96 patients with either Bankart lesions or ALPSA lesions with the additional inclusion criteria as follows: (1) clinical history of involuntary, recurrent anterior shoulder instability with traumatic onset; (2) labral repair and capsule retensioning by use of a single arthroscopic technique with suture anchors; (3) no previous stabilizing surgery; and (4) no glenoid defects of greater than 25% of the glenoid circumference. Ninety-three shoulders in 89 of the 96 patients were available with a minimum follow-up of 2 years. Seven were lost to follow-up because they either moved away or could not be reached. A retrospective review of both office and surgical records was performed. All patients had both video and photo documentation of pathology, and in all cases operative findings were recorded at the time of surgery with specific attention to capsular laxity, bony injury, and labral pathology. Labral detachment from the glenoid rim was present in all patients (100%). A discrete Bankart lesion was defined as an obvious detachment of the labrum but without loss of the normal labral anatomy, and this was observed in 67 shoulders (72%) (Fig 1). An ALPSA lesion was defined as loss of the normal labral attachment with the appearance of the capsule scarred along the glenoid rim medial to its normal attachment and without a robust labral structure. This lesion was observed in 26 shoulders (28%) (Fig 2). We analyzed these 2 groups of patients with regard to age, number of dislocations, and range of motion preoperatively
METHODS Patient Selection Over a 6-year period (1999-2004), the senior author performed 344 surgeries for anterior shoulder instability; 242 of these cases were arthroscopic capsulorrhaphy procedures, and 41 were open repairs for capsular insufficiency with or without an associated
FIGURE 2. ALPSA lesion. The capsulolabral complex appears to be detached from the edge of the glenoid, displaced, and healed medially on the glenoid neck.
RESULTS OF ARTHROSCOPIC CAPSULOLABRAL REPAIR TABLE 1.
Gender Dominant side Mean follow-up (mo) Mean age at time of injury (yr) Mean age at time of surgery (yr) No. of dislocations/subluxations
Patient Data
ALPSA Lesion (n ⫽ 26)
Bankart Lesion (n ⫽ 67)
73% male 65% 48 (24-92) 21.4 (14-35) 24.7 (15-36) 12.3 (2-57)
80% male 64% 46 (24-98) 30.4 (15-57) 35 (15-61) 4.9 (2-24)
and recurrence of dislocations and range of motion postoperatively (Table 1). In addition, all patients underwent a preoperative imaging evaluation, including anteroposterior and axillary radiographs, as well as a computed tomography arthrogram (23 patients) or magnetic resonance imaging arthrogram (70 patients). The presence of capsular laxity or defects, chondral or bony defects, and/or glenohumeral osteoarthritis was correlated with intraoperative arthroscopic findings and was recorded. Examination with the patient under anesthesia included evaluation of anterior as well posterior glenohumeral translation and degree of sulcus sign. Glenohumeral translation was graded as follows: grade I, humeral head translation up to but not over the glenoid rim; grade II, humeral head translation over the rim of the glenoid that spontaneously reduces; and grade III, dislocation of the glenohumeral joint. The sulcus sign was graded as follows: grade I, inferior humeral head translation of up to 1 cm; grade II, inferior translation of 2 cm; and grade III, inferior translation of 3 cm. None of the patients had a sulcus sign above grade I. All patients had either grade II or III anterior glenohumeral translation, but none had posterior translation (Table 2). Surgical Technique All surgeries were performed by use of a standardized technique by the senior surgeon. The patient was placed on a beach chair in the supine position, and after interscalene regional nerve block was obtained, he or she was placed in the upright-seated position. Examination of the glenohumeral joint with the arm in various degrees of abduction and external rotation under anesthesia was performed to confirm the degree and direction of instability. Arthroscopy was then performed by use of the standard portals. The posterior portal was created 1.5 cm inferior and medial to the posterolateral corner of the acromion. The anterosuperior portal was created, and a 5.5-mm cannula was placed there, followed by an anteroinferior portal with an 8-mm cannula placed approximately 1 cm
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P Value ⬎ ⬎ ⬎ ⬍ ⬍ ⬍
.05 .05 .05 .05 .05 .05
Total (N ⫽ 93) 78% male 64% 47 (24-98) 27.9 (14-57) 32 (15-61) 6.9 (2-57)
inferior and lateral to the coracoid process. A complete evaluation of the capsular and osseous lesions was then performed by use of both 30° and 70° arthroscopes (Table 2). Additional pathologies were detected and treated. Mobilization of the inferior glenohumeral ligament was then performed before the repair. In the case of a Bankart lesion, less mobilization was required than in the case of an ALPSA lesion. In both cases both a knife rasp and a hook-tip electrocautery device (VAPR; DePuy Mitek, Raynham, MA) were used to mobilize the capsulolabral tissue. In the case of an ALPSA lesion, this mobilization was always performed by use of a 70° arthroscope to ensure that the tissue was sufficiently freed from its position and healed medially on the scapular neck. The glenoid neck was then decorticated with the use of a motorized shaver. The first anchor was routinely placed at the 5-o’clock position or lower on the glenoid on the edge of the articular cartilage, and this was an absorbable anchor loaded with No. 2 nonabsorbable suture material (Panalok; DePuy Mitek). The sutures from this anchor were then placed in an inferior and lateral position through the inferior glenohumeral ligament in an effort to not only anatomically restore the position of the capsulolabral tissue but also shift the capsule from inferior and lateral to superior and medial. Sutures were passed with the Spectrum device (Linvatec, Largo, FL). Additional anchors were then placed higher along the glenoid rim at the 4-o’clock, 3-o’clock, and, sometimes, 2-o’clock position. The mean number of anchors used was 3.26 (range, 1 to 5), with 3.46 (range, 2 to 5) in the ALPSA group and 3.19 (range, 1 to 5) in the Bankart group. Postoperative Care The patient maintained his or her arm in a sling for 4 weeks, after which active range of motion was commenced and activities of daily living were permitted with the operated arm. Strengthening was delayed until 3 months after surgery, and sports participation
⬎ .05 25 (26.8) ⬎ .05 11 (11.8%) ⬍ .05 7 (7.5%) ⬎ .05 5 (5.3%) 49 (53%)
11 (42%)
Grade II in 46 (49%) and grade III in 47 (51%)
⬎ .05 27 (29%)
⬍ .05 46 (49.4%)
⬎ .05 64 (68.8%)
⬍ .05 9 (9.6%)
⬎ .05 9 (9.6%)
8 (30.7%) 4 (15.3%) 1 (3.8%) 0 0 1 (3.8%) 9 (34.6%)
6 (23%)
21 (80.7%)
7 (10.4%) 8 (11.9%) 9 (13.5%) 7 (10.4%)
Bankart lesion (n ⫽ 67) ALPSA lesion (n ⫽ 26) P value Total (N ⫽ 93)
38 (57%)
Grade II in 41 (61%) and grade III in 26 (39%) Grade II in 5 (19%) and grade III in 21 (81%)
18 (26.8%)
4 (5.9%)
40 (59.7%)
43 (64.1%)
Glenoid Erosion Bony Bankart Chondral Lesion Normal Partial Rotator Cuff Tear SLAP Lesion Capsular Rupture Capsular Laxity Anterior Translation Grade Grade I Sulcus Sign
Osseous Lesion (⬍25% of Glenoid Surface)
Glenoid Surface
Operative Findings of Patients TABLE 2.
12 (17.9%)
M. OZBAYDAR ET AL. Hill-Sachs Lesion
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commenced at 4 months for noncollision and noncontact sports. Collision and contact sports participation was delayed until 6 months after surgery. Functional Evaluation All patients were evaluated postoperatively at 4 months, 6 months, and 12 months and then on a yearly basis. Physical examination included shoulder range of motion and instability signs (apprehension test and relocation test). The Rowe score was determined for functional evaluation. Definition of Failure The recurrence of instability as determined by either a subjective sense of subluxation or objective documentation of dislocation was considered a failure. Statistical Analysis Both 1-tailed difference-of-proportions tests and Student t tests were performed for analyses of differences in the patient populations and outcomes. P ⬍ .05 was set as the level of significance. RESULTS Of the shoulders, 60 had a history of recurrent dislocations and 33 had recurrent subluxations preoperatively. Of the patients, 57 (61%) were involved in sports, and 5 (5.3%) played at a competitive level in either high school or college. The mean number of dislocations or subluxations was significantly higher in the patients with ALPSA lesions (mean, 12.3 dislocations [range, 2 to 57]) than in the Bankart group (mean, 4.9 dislocations [range, 2 to 24]) (P ⬍ .001). Both groups were similar with respect to dominance and follow-up time (P ⬎ .05). In addition, there was no significant difference in the number of anchors used (P ⬎ .05), number of glenoid erosions (P ⬎ .05), or number of bony Bankart lesions (P ⬎ .05) between the groups (Table 2). At a mean follow-up of 47 months (range, 24 to 98 months), 10 of the 93 shoulders (10.7%) in the entire group had a recurrence (dislocation/subluxation). Of these 10 patients, 5 had Bankart lesions (7.4%) and 5 had ALPSA lesions (19.2%). The higher rate of recurrent instability after arthroscopic repair in the ALPSA group was statistically significant (P ⫽ .0501). All 10 patients with recurrence had at least 3 anchors that were used for the repair. Of the 10 patients who had recurrent instability after arthroscopic repair, 6 underwent revision surgery.
RESULTS OF ARTHROSCOPIC CAPSULOLABRAL REPAIR Four of the six patients were from the ALPSA group and two from the Bankart group. Revision arthroscopic Bankart repair with capsular shift was performed in one patient and revision open Bankart repair with capsular shift was performed in the other patient from the Bankart group. Both patients had stable shoulders at a mean of 36 months (28 and 45 months) of follow-up. Two patients from the failed ALPSA group underwent open repair of the ALPSA lesion with capsular shift; however, both repairs failed within 1 year (8 and 12 months). These 2 patients and the other 2 patients from the failed ALPSA group underwent open revision surgery with a Latarjet procedure,24,25 which resulted in stable shoulders in all 4 patients at a mean follow-up of 40 months (range, 13 to 55 months). The 4 remaining patients in whom the primary stabilization procedures failed declined additional surgery. Functional Results In the patients without recurrence of instability, the Rowe score was no different for either group (P ⬎ .05): the ALPSA group had a Rowe score of 86.2 points (range, 50 to 100), and the Bankart group had a score of 87.2 points (range, 40 to 100). Overall, 79 shoulders in 75 patients (85%) had good or excellent results. Functional results of the patients according to lesion type, either ALPSA or Bankart, are summarized in Table 3. Complications Two patients had persistent pain after surgery despite stable shoulders with good range of motion. Radiographic follow-up in these patients showed evidence of glenohumeral arthritis. Both were able to manage their pain with occasional intake of antiinflammatory medication. Two other patients had pain mostly related to postoperative stiffness. Both patients were lacking greater than 20° of passive elevation and external rotation. Arthroscopic release was performed in one of them, which resulted in resolution of pain
TABLE 3.
Follow-up (mo) Functional results (Rowe score) No. of shoulders with good or excellent results
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and restoration of near-full range of motion. The other patient declined additional surgery. DISCUSSION Tear of the glenoid labrum may result in loss of the normal socket depth of the glenoid with resultant loss of the concavity-compression stability mechanism of the shoulder joint.26 Recurrent anterior glenohumeral instability results in detachment of the capsulolabral stabilizing tissue, which may heal in a medialized position. Broca and Hartmann27 reported on the anterior dislocation of the shoulder in 1890, first describing a periosteal sleeve avulsion lesion in detail. Later, DePalma et al.,28 McLaughlin,29 and Moseley and Overgaard30 noted the periosteal sleeve avulsion, including acute and old lesions, as a distinctive category of intra-articular lesions involving anterior shoulder dislocations.31 Neviaser7 in 1993 reported on this condition based on his arthroscopic observations, which he termed an ALPSA lesion. He identified that in some patients the labrum-ligament complex was detached and healed medially on the scapular neck and that this group was to be distinguished from those patients who had a clear separation of the labrum and capsule that was labeled a classic Bankart lesion. He pointed out the importance of adequate mobilization of the scarred capsulolabral complex so that it could be reattached at the articular rim of the glenoid to restore the proper origin of the inferior glenohumeral ligament. Whether this improvement in technique resulted in a low recurrence of dislocations or a recurrence rate similar to that with repair of Bankart lesions was not reported previously in the literature. Several investigators have reported failure rates ranging from 0% to 7.5% after arthroscopic Bankart repair with suture anchors.11,19,20,22,23,32-35 Boileau et al.,33 Carreira et al.,36 and Kandziora et al.37 reported failure rates between 10% and 16.5%. In our patient cohort treated with arthroscopic suture anchor repair, we observed a recurrence rate for instability of
Functional Results of Patients With Arthroscopic Anterior Stabilization ALPSA Lesion (n ⫽ 26)
Bankart Lesion (n ⫽ 67)
P Value
Total (N ⫽ 93)
49 (24-92) 86.2 (50-100)
46 (24-98) 87.2 (40-100)
⬎ .05 ⬎ .05
47 (24-96) 86.8 (40-100)
21 (80.7%)
58 (86.5%)
⬎ .05
79 (85%)
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10.7% after a mean follow-up of 47 months, which is comparable to several of these recent reports using similar methods of repair. Boileau et al. suggested that the use of fewer than 4 anchors was associated with a higher failure rate, whereas the other authors attributed the increased risk of failure to the presence of bony lesions or capsular laxity. No patient in our study had a glenoid bony deficiency of more than 25%, and none had capsular laxity, deficiency, or rupture. All patients in whom the arthroscopic repair failed had at least 3 anchors. We do not believe that the addition of more anchors in some of these patients would have decreased the recurrence rate because we observed that the use of a mean of 3 anchors or more gave a failure rate of about 7% in the Bankart group, which was equivalent to the failure rate in the study by Boileau et al. Habermeyer et al.2 evaluated the evolution of intraarticular disease in post-traumatic shoulder instability using arthroscopy. They concluded that recurrences progressively damage stabilizing structures. They did not, however, correlate high recurrences specifically with the development of an ALPSA lesion. Spatschil et al.,38 in a prospective multicenter study, evaluated intra-articular lesions in glenohumeral instability and correlated these with clinical findings. However, ALPSA and Bankart lesions were grouped together in their study, thus confirming the findings of Habermeyer et al. They suggested that early surgical stabilization after post-traumatic anterior-inferior shoulder dislocations should be recommended to prevent increasing damage within the shoulder joint. However, in both studies, the authors did not consider patients’ anatomic and clinical outcomes. Thus, it was not possible to draw conclusions about the therapeutic implications of their study. Yiannakopoulos et al.39 showed in a recent study that 78% of patients with acute dislocation had Bankart lesions whereas 97% of patients with recurrent (chronic) dislocations had either Bankart or ALPSA lesions. All patients with ALPSA lesions were found in the chronic group. It was observed in this study that the number of shoulder dislocations was significantly higher in patients who presented with ALPSA lesions versus those who had Bankart lesions. Thus we agree with Habermeyer et al.,2 who suggested that an ALPSA lesion is the recurrence-dependent evolution of a Bankart lesion during progressive instability. We would postulate that progressive damage to the capsule and labrum results in loss of the normal robust capsulolabral structure over time. Therefore the result of repair of this
tissue, though having the appearance of a Bankarttype repair, is weaker than that with repair of less damaged capsulolabral tissue in the case of a classic Bankart lesion. Alternative surgical treatment including open capsulolabral repair or the addition of an anterior glenoid bony block to compensate for the poor-quality tissues should be considered.24,25 There are a number of limitations to this study. First, it is a retrospective study, and as with any other retrospective study, it is based on observations of outcome in a case series of patients who had certain injury and on whom specific surgery was performed. The outcome results are not statistically as powerful as those of a prospective randomized study. Second, when the 2 groups in this review are compared, the number of shoulders with simple Bankart lesions (67 shoulders) is much higher than the number with ALPSA lesions (26 shoulders). The difference in number between the 2 groups decreases the strength of the statistical analysis. Third, in a good number of patients presented in this series, the follow-up was only 2 years. A longer follow-up may show different results than those presented in this report, and thus the results of this study should be considered short-term to midterm outcomes. CONCLUSIONS Patients with ALPSA lesions present with a higher number of recurrent dislocations than those with discrete Bankart lesions. According to the results of this study, the recurrence of instability after arthroscopic capsulolabral repair for an ALPSA lesion is twice as high as the recurrence after repair of a classic Bankart lesion. REFERENCES 1. Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC. Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197. 2. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: A prospective study. J Shoulder Elbow Surg 1999;8:66-74. 3. Hintermann B, Gachter A. Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995;23:545-551. 4. Speer KP, Deng X, Borrero S, Torzilli PA, Altchek DA, Warren RF. Biomechanical evaluation of a simulated Bankart lesion. J Bone Joint Surg Am 1994;76:1819-1826. 5. Turkel SJ, Panio MW, Marshall JL, Girgis FG. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am 1981;63:1208-1217. 6. Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 1990;18:25-28.
RESULTS OF ARTHROSCOPIC CAPSULOLABRAL REPAIR 7. Neviaser TJ. The anterior labroligamentous periosteal sleeve avulsion lesion: A cause of anterior instability of the shoulder. Arthroscopy 1993;9:17-21. 8. Cole BJ, L’Insalata J, Irrgang J, Warner JJ. Comparison of arthroscopic and open anterior shoulder stabilization. A two to six-year follow-up study. J Bone Joint Surg Am 2000;82: 1108-1114. 9. Jobe FW, Giangarra CE, Kvitne RS, Glousman RE. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 1991;19:428-434. 10. 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;24:144148. 11. Kim SH, Ha KI. Bankart repair in traumatic anterior shoulder instability: Open versus arthroscopic technique. Arthroscopy 2002;18:755-763. 12. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: A long-term end-result study. J Bone Joint Surg Am 1978;60: 1-16. 13. Wolf EM. Arthroscopic capsulolabral repair using suture anchors. Orthop Clin North Am 1993;24:59-69. 14. 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. 15. Jorgensen U, Svend-Hansen H, Bak K, Pedersen I. Recurrent post-traumatic anterior shoulder dislocation-open versus arthroscopic repair. Knee Surg Sports Traumatol Arthrosc 1999; 7:118-24. 16. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic treatment of multidirectional shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 1997;13: 418-425. 17. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic treatment of posterior shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 1997;13:426-432. 18. Savoie FH III, Miller CD, Field LD. Arthroscopic reconstruction of traumatic anterior instability of the shoulder: The Caspari technique. Arthroscopy 1997;13:201-209. 19. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677694. 20. Grana WA, Buckley PD, Yates CK. Arthroscopic Bankart suture repair. Am J Sports Med 1993;21:348-353. 21. Laurencin CT, Stephens S, Warren RF, Altchek DW. Arthroscopic Bankart repair using a degradable tack. A followup study using optimized indications. Clin Orthop Relat Res 1996:132-137. 22. Pagnani MJ, Warren RF, Altchek DW, Wickiewicz TL, Anderson AF. Arthroscopic shoulder stabilization using transglenoid sutures. A four-year minimum followup. Am J Sports Med 1996;24:459-467. 23. Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S.
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Arthroscopic stabilization for recurrent anterior shoulder dislocation: Results of 59 cases. Arthroscopy 1995;11:173-179. Latarjet M. Technique de la butee coracoidienne pre-glenoidienne dans le traitement des luxations recidivantes de l’epaule. Lyon Chir 1958;54:604-607. Helfet AJ. Coracoid transplantation for recurring dislocation of the shoulder. J Bone Joint Surg Br 1958;40:198-202. Fehringer EV, Schmidt GR, Boorman RS, et al. The anteroinferior labrum helps center the humeral head on the glenoid. J Shoulder Elbow Surg 2003;12:53-58. Broca A, Hartmann H. Contribution a l’etude des luxations de l’epaule (luxations dites incompletes, decollements periostiques, luxations directes et luxations indirections). Bull Soc Anat Paris 1890;4:312-336. DePalma A, Cooke A, Prabhakar M. The role of the subscapularis in recurrent anterior dislocations of the shoulder. Clin Orthop 1967;54:35-49. McLaughlin H. Recurrent anterior dislocation of the shoulder. Am J Surg 1960;99:628-632. Moseley H, Overgaard B. The anterior capsular mechanism in recurrent anterior dislocation of the shoulder. Morphological and clinical studies with special reference to the glenoid labrum and the glenohumeral ligaments. J Bone Joint Surg Br 1962;44:913-927. Yoneda M. Neviaser’s contribution to the treatment of ALPSA lesions. J Bone Joint Surg Am 2001;83:621-622. Abrams JS, Savoie FH III, Tauro JC, Bradley JP. Recent advances in the evaluation and treatment of shoulder instability: Anterior, posterior, and multidirectional. Arthroscopy 2002;18:1-13 (suppl 2). Boileau P, Villalba M, Hery JY, Balg F, Ahrens P, Neyton L. Risk factors for recurrence of shoulder instability after arthroscopic Bankart repair. J Bone Joint Surg Am 2006;88:17551763. 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;82:991-1003. Gerber C, Nyffeler RW. Classification of glenohumeral joint instability. Clin Orthop Relat Res 2002:65-76. Carreira DS, Mazzocca AD, Oryhon J, Brown FM, Hayden JK, Romeo AA. A prospective outcome evaluation of arthroscopic Bankart repairs: Minimum 2-year follow-up. Am J Sports Med 2006;34:771-777. Kandziora F, Jager 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;16:359-366. Spatschil A, Landsiedl F, Anderl W, et al. Posttraumatic anterior-inferior instability of the shoulder: Arthroscopic findings and clinical correlations. Arch Orthop Trauma Surg 2006; 126:217-222. Yiannakopoulos CK, Mataragas E, Antonogiannakis E. A comparison of the spectrum of intra-articular lesions in acute and chronic anterior shoulder instability. Arthroscopy 2007; 23:985-990.
Purpose: The purpose of this study was to evaluate the results of arthroscopic capsulolabral repair for traumatic anterior shoulder instability and to compare the outcome in patients who have Bankart lesions versus those with anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions. Methods: This study included 99 patients (93 shoulders), 72 male and 17 female, with a mean age of 32 years, who underwent arthroscopic Bankart repair for traumatic, recurrent anterior shoulder instability, by use of suture anchors. In 67 shoulders (72%) a discrete Bankart lesion was repaired, and in 26 shoulders (28%) an ALPSA lesion was repaired. The 2 groups were analyzed with regard to the number of preoperative dislocations and number of postoperative recurrences. Results: At a mean follow-up of 47 months (range, 24 to 98 months), recurrence of instability was documented in 10 shoulders (10.7%). Of the shoulders, 5 had Bankart lesions (7.4%) and 5 had ALPSA lesions (19.2%) (P ⫽ .0501). The mean number of dislocations or subluxations before the index surgery was significantly higher in the ALPSA group (mean, 12.3 [range, 2 to 57]) than in the Bankart group (mean, 4.9 [range, 2 to 24]) (P ⬍ .05). However, there were no significant differences in the number of anchors used, incidence of minor glenoid erosion, or incidence of bony Bankart lesions between the groups (P ⬎ .05 for all). Conclusions: Patients with ALPSA lesions present with a higher number of recurrent dislocations than those with discrete Bankart lesions. In addition, the failure rate after arthroscopic capsulolabral repair is higher in the ALPSA group than in the Bankart group. Level of Evidence: Level IV, therapeutic case series. Key Words: Shoulder—Anterior instability—Arthroscopy—Bankart repair— Anterior labroligamentous periosteal sleeve avulsion lesion—Suture anchor.
T
he loss of the stabilizing effects of the bony glenohumeral joint, static capsulolabral tissue, and dynamic muscle compression after shoulder dis-
From the Harvard Shoulder Service (M.O., D.D., D.M., L.D.H., J.J.P.W.); Department of Sports Medicine and Shoulder Service, Harvard Medical School, Brigham and Women’s Hospital (L.D.H.); Department of Orthopaedic Surgery, Harvard Medical School (J.J.P.W.); Massachusetts General Hospital (J.J.P.W.), Boston, Massachusetts; and Mayo Clinic (B.E.), Rochester, Minnesota, U.S.A. The authors report no conflict of interest. Received October 7, 2007; accepted January 23, 2008. Address correspondence and reprint requests to Jon J. P. Warner, M.D., Harvard Shoulder Service, 55 Fruit St, Boston, MA 02114, U.S.A. E-mail: [email protected] © 2008 by the Arthroscopy Association of North America 0749-8063/08/2411-7519$34.00/0 doi:10.1016/j.arthro.2008.01.017
location has been well documented in the literature.1-5 Detachment of the anterior labrum from the glenoid represents disruption of the origin of the inferior glenohumeral ligament, and this has been termed the essential lesion in shoulder instability.3,5,6 In some patients with recurrent anterior glenohumeral instability, the labrum may heal in a medialized position. Neviaser’s 1993 report on this condition was based on his arthroscopic observations that the pathology appeared as an anterior labroligamentous periosteal sleeve avulsion injury, which he termed an ALPSA lesion.7 He identified that in some patients the capsulolabral complex was detached and healed medially on the scapular neck, and this group was distinguished from those patients who had a very clear separation of the labrum and capsule, which represents the classic Bankart lesion.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 11 (November), 2008: pp 1277-1283
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FIGURE 1. Bankart lesion. Apparent detachment of the labrum from the edge of the glenoid is seen.
Although open Bankart repair has been recognized as the gold standard for the treatment of anterior shoulder instability,1,8-13 arthroscopic repair has been shown to be equally effective in many series.8,11,14,15 Moreover, this method of treatment offers advantages of outpatient surgery, better cosmesis, less pain, and more accurate detection of comorbid pathology.16-18 Factors that have a negative prognosis on the success rate of arthroscopic repair include significant bony lesions of the glenoid or humerus, marked capsular laxity or deficiency, and the use of fewer anchors.4,5,8,19-23 The prognostic implication of arthroscopic ALPSA lesion repair has not been previously reported. The purpose of our study was to review our experience with arthroscopic capsulolabral repair in the case of traumatic, recurrent instability and do so in the context of Bankart lesions versus ALPSA lesions. We hypothesized that patients with ALPSA lesions would have a higher recurrence rate after arthroscopic capsulolabral repair for recurrent instability and that this would correlate with a greater incidence of instability episodes before surgery.
subscapularis tear. Bony reconstruction for marked loss of the anterior glenoid was done in 61 patients. We identified a consecutive series of 96 patients with either Bankart lesions or ALPSA lesions with the additional inclusion criteria as follows: (1) clinical history of involuntary, recurrent anterior shoulder instability with traumatic onset; (2) labral repair and capsule retensioning by use of a single arthroscopic technique with suture anchors; (3) no previous stabilizing surgery; and (4) no glenoid defects of greater than 25% of the glenoid circumference. Ninety-three shoulders in 89 of the 96 patients were available with a minimum follow-up of 2 years. Seven were lost to follow-up because they either moved away or could not be reached. A retrospective review of both office and surgical records was performed. All patients had both video and photo documentation of pathology, and in all cases operative findings were recorded at the time of surgery with specific attention to capsular laxity, bony injury, and labral pathology. Labral detachment from the glenoid rim was present in all patients (100%). A discrete Bankart lesion was defined as an obvious detachment of the labrum but without loss of the normal labral anatomy, and this was observed in 67 shoulders (72%) (Fig 1). An ALPSA lesion was defined as loss of the normal labral attachment with the appearance of the capsule scarred along the glenoid rim medial to its normal attachment and without a robust labral structure. This lesion was observed in 26 shoulders (28%) (Fig 2). We analyzed these 2 groups of patients with regard to age, number of dislocations, and range of motion preoperatively
METHODS Patient Selection Over a 6-year period (1999-2004), the senior author performed 344 surgeries for anterior shoulder instability; 242 of these cases were arthroscopic capsulorrhaphy procedures, and 41 were open repairs for capsular insufficiency with or without an associated
FIGURE 2. ALPSA lesion. The capsulolabral complex appears to be detached from the edge of the glenoid, displaced, and healed medially on the glenoid neck.
RESULTS OF ARTHROSCOPIC CAPSULOLABRAL REPAIR TABLE 1.
Gender Dominant side Mean follow-up (mo) Mean age at time of injury (yr) Mean age at time of surgery (yr) No. of dislocations/subluxations
Patient Data
ALPSA Lesion (n ⫽ 26)
Bankart Lesion (n ⫽ 67)
73% male 65% 48 (24-92) 21.4 (14-35) 24.7 (15-36) 12.3 (2-57)
80% male 64% 46 (24-98) 30.4 (15-57) 35 (15-61) 4.9 (2-24)
and recurrence of dislocations and range of motion postoperatively (Table 1). In addition, all patients underwent a preoperative imaging evaluation, including anteroposterior and axillary radiographs, as well as a computed tomography arthrogram (23 patients) or magnetic resonance imaging arthrogram (70 patients). The presence of capsular laxity or defects, chondral or bony defects, and/or glenohumeral osteoarthritis was correlated with intraoperative arthroscopic findings and was recorded. Examination with the patient under anesthesia included evaluation of anterior as well posterior glenohumeral translation and degree of sulcus sign. Glenohumeral translation was graded as follows: grade I, humeral head translation up to but not over the glenoid rim; grade II, humeral head translation over the rim of the glenoid that spontaneously reduces; and grade III, dislocation of the glenohumeral joint. The sulcus sign was graded as follows: grade I, inferior humeral head translation of up to 1 cm; grade II, inferior translation of 2 cm; and grade III, inferior translation of 3 cm. None of the patients had a sulcus sign above grade I. All patients had either grade II or III anterior glenohumeral translation, but none had posterior translation (Table 2). Surgical Technique All surgeries were performed by use of a standardized technique by the senior surgeon. The patient was placed on a beach chair in the supine position, and after interscalene regional nerve block was obtained, he or she was placed in the upright-seated position. Examination of the glenohumeral joint with the arm in various degrees of abduction and external rotation under anesthesia was performed to confirm the degree and direction of instability. Arthroscopy was then performed by use of the standard portals. The posterior portal was created 1.5 cm inferior and medial to the posterolateral corner of the acromion. The anterosuperior portal was created, and a 5.5-mm cannula was placed there, followed by an anteroinferior portal with an 8-mm cannula placed approximately 1 cm
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P Value ⬎ ⬎ ⬎ ⬍ ⬍ ⬍
.05 .05 .05 .05 .05 .05
Total (N ⫽ 93) 78% male 64% 47 (24-98) 27.9 (14-57) 32 (15-61) 6.9 (2-57)
inferior and lateral to the coracoid process. A complete evaluation of the capsular and osseous lesions was then performed by use of both 30° and 70° arthroscopes (Table 2). Additional pathologies were detected and treated. Mobilization of the inferior glenohumeral ligament was then performed before the repair. In the case of a Bankart lesion, less mobilization was required than in the case of an ALPSA lesion. In both cases both a knife rasp and a hook-tip electrocautery device (VAPR; DePuy Mitek, Raynham, MA) were used to mobilize the capsulolabral tissue. In the case of an ALPSA lesion, this mobilization was always performed by use of a 70° arthroscope to ensure that the tissue was sufficiently freed from its position and healed medially on the scapular neck. The glenoid neck was then decorticated with the use of a motorized shaver. The first anchor was routinely placed at the 5-o’clock position or lower on the glenoid on the edge of the articular cartilage, and this was an absorbable anchor loaded with No. 2 nonabsorbable suture material (Panalok; DePuy Mitek). The sutures from this anchor were then placed in an inferior and lateral position through the inferior glenohumeral ligament in an effort to not only anatomically restore the position of the capsulolabral tissue but also shift the capsule from inferior and lateral to superior and medial. Sutures were passed with the Spectrum device (Linvatec, Largo, FL). Additional anchors were then placed higher along the glenoid rim at the 4-o’clock, 3-o’clock, and, sometimes, 2-o’clock position. The mean number of anchors used was 3.26 (range, 1 to 5), with 3.46 (range, 2 to 5) in the ALPSA group and 3.19 (range, 1 to 5) in the Bankart group. Postoperative Care The patient maintained his or her arm in a sling for 4 weeks, after which active range of motion was commenced and activities of daily living were permitted with the operated arm. Strengthening was delayed until 3 months after surgery, and sports participation
⬎ .05 25 (26.8) ⬎ .05 11 (11.8%) ⬍ .05 7 (7.5%) ⬎ .05 5 (5.3%) 49 (53%)
11 (42%)
Grade II in 46 (49%) and grade III in 47 (51%)
⬎ .05 27 (29%)
⬍ .05 46 (49.4%)
⬎ .05 64 (68.8%)
⬍ .05 9 (9.6%)
⬎ .05 9 (9.6%)
8 (30.7%) 4 (15.3%) 1 (3.8%) 0 0 1 (3.8%) 9 (34.6%)
6 (23%)
21 (80.7%)
7 (10.4%) 8 (11.9%) 9 (13.5%) 7 (10.4%)
Bankart lesion (n ⫽ 67) ALPSA lesion (n ⫽ 26) P value Total (N ⫽ 93)
38 (57%)
Grade II in 41 (61%) and grade III in 26 (39%) Grade II in 5 (19%) and grade III in 21 (81%)
18 (26.8%)
4 (5.9%)
40 (59.7%)
43 (64.1%)
Glenoid Erosion Bony Bankart Chondral Lesion Normal Partial Rotator Cuff Tear SLAP Lesion Capsular Rupture Capsular Laxity Anterior Translation Grade Grade I Sulcus Sign
Osseous Lesion (⬍25% of Glenoid Surface)
Glenoid Surface
Operative Findings of Patients TABLE 2.
12 (17.9%)
M. OZBAYDAR ET AL. Hill-Sachs Lesion
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commenced at 4 months for noncollision and noncontact sports. Collision and contact sports participation was delayed until 6 months after surgery. Functional Evaluation All patients were evaluated postoperatively at 4 months, 6 months, and 12 months and then on a yearly basis. Physical examination included shoulder range of motion and instability signs (apprehension test and relocation test). The Rowe score was determined for functional evaluation. Definition of Failure The recurrence of instability as determined by either a subjective sense of subluxation or objective documentation of dislocation was considered a failure. Statistical Analysis Both 1-tailed difference-of-proportions tests and Student t tests were performed for analyses of differences in the patient populations and outcomes. P ⬍ .05 was set as the level of significance. RESULTS Of the shoulders, 60 had a history of recurrent dislocations and 33 had recurrent subluxations preoperatively. Of the patients, 57 (61%) were involved in sports, and 5 (5.3%) played at a competitive level in either high school or college. The mean number of dislocations or subluxations was significantly higher in the patients with ALPSA lesions (mean, 12.3 dislocations [range, 2 to 57]) than in the Bankart group (mean, 4.9 dislocations [range, 2 to 24]) (P ⬍ .001). Both groups were similar with respect to dominance and follow-up time (P ⬎ .05). In addition, there was no significant difference in the number of anchors used (P ⬎ .05), number of glenoid erosions (P ⬎ .05), or number of bony Bankart lesions (P ⬎ .05) between the groups (Table 2). At a mean follow-up of 47 months (range, 24 to 98 months), 10 of the 93 shoulders (10.7%) in the entire group had a recurrence (dislocation/subluxation). Of these 10 patients, 5 had Bankart lesions (7.4%) and 5 had ALPSA lesions (19.2%). The higher rate of recurrent instability after arthroscopic repair in the ALPSA group was statistically significant (P ⫽ .0501). All 10 patients with recurrence had at least 3 anchors that were used for the repair. Of the 10 patients who had recurrent instability after arthroscopic repair, 6 underwent revision surgery.
RESULTS OF ARTHROSCOPIC CAPSULOLABRAL REPAIR Four of the six patients were from the ALPSA group and two from the Bankart group. Revision arthroscopic Bankart repair with capsular shift was performed in one patient and revision open Bankart repair with capsular shift was performed in the other patient from the Bankart group. Both patients had stable shoulders at a mean of 36 months (28 and 45 months) of follow-up. Two patients from the failed ALPSA group underwent open repair of the ALPSA lesion with capsular shift; however, both repairs failed within 1 year (8 and 12 months). These 2 patients and the other 2 patients from the failed ALPSA group underwent open revision surgery with a Latarjet procedure,24,25 which resulted in stable shoulders in all 4 patients at a mean follow-up of 40 months (range, 13 to 55 months). The 4 remaining patients in whom the primary stabilization procedures failed declined additional surgery. Functional Results In the patients without recurrence of instability, the Rowe score was no different for either group (P ⬎ .05): the ALPSA group had a Rowe score of 86.2 points (range, 50 to 100), and the Bankart group had a score of 87.2 points (range, 40 to 100). Overall, 79 shoulders in 75 patients (85%) had good or excellent results. Functional results of the patients according to lesion type, either ALPSA or Bankart, are summarized in Table 3. Complications Two patients had persistent pain after surgery despite stable shoulders with good range of motion. Radiographic follow-up in these patients showed evidence of glenohumeral arthritis. Both were able to manage their pain with occasional intake of antiinflammatory medication. Two other patients had pain mostly related to postoperative stiffness. Both patients were lacking greater than 20° of passive elevation and external rotation. Arthroscopic release was performed in one of them, which resulted in resolution of pain
TABLE 3.
Follow-up (mo) Functional results (Rowe score) No. of shoulders with good or excellent results
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and restoration of near-full range of motion. The other patient declined additional surgery. DISCUSSION Tear of the glenoid labrum may result in loss of the normal socket depth of the glenoid with resultant loss of the concavity-compression stability mechanism of the shoulder joint.26 Recurrent anterior glenohumeral instability results in detachment of the capsulolabral stabilizing tissue, which may heal in a medialized position. Broca and Hartmann27 reported on the anterior dislocation of the shoulder in 1890, first describing a periosteal sleeve avulsion lesion in detail. Later, DePalma et al.,28 McLaughlin,29 and Moseley and Overgaard30 noted the periosteal sleeve avulsion, including acute and old lesions, as a distinctive category of intra-articular lesions involving anterior shoulder dislocations.31 Neviaser7 in 1993 reported on this condition based on his arthroscopic observations, which he termed an ALPSA lesion. He identified that in some patients the labrum-ligament complex was detached and healed medially on the scapular neck and that this group was to be distinguished from those patients who had a clear separation of the labrum and capsule that was labeled a classic Bankart lesion. He pointed out the importance of adequate mobilization of the scarred capsulolabral complex so that it could be reattached at the articular rim of the glenoid to restore the proper origin of the inferior glenohumeral ligament. Whether this improvement in technique resulted in a low recurrence of dislocations or a recurrence rate similar to that with repair of Bankart lesions was not reported previously in the literature. Several investigators have reported failure rates ranging from 0% to 7.5% after arthroscopic Bankart repair with suture anchors.11,19,20,22,23,32-35 Boileau et al.,33 Carreira et al.,36 and Kandziora et al.37 reported failure rates between 10% and 16.5%. In our patient cohort treated with arthroscopic suture anchor repair, we observed a recurrence rate for instability of
Functional Results of Patients With Arthroscopic Anterior Stabilization ALPSA Lesion (n ⫽ 26)
Bankart Lesion (n ⫽ 67)
P Value
Total (N ⫽ 93)
49 (24-92) 86.2 (50-100)
46 (24-98) 87.2 (40-100)
⬎ .05 ⬎ .05
47 (24-96) 86.8 (40-100)
21 (80.7%)
58 (86.5%)
⬎ .05
79 (85%)
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10.7% after a mean follow-up of 47 months, which is comparable to several of these recent reports using similar methods of repair. Boileau et al. suggested that the use of fewer than 4 anchors was associated with a higher failure rate, whereas the other authors attributed the increased risk of failure to the presence of bony lesions or capsular laxity. No patient in our study had a glenoid bony deficiency of more than 25%, and none had capsular laxity, deficiency, or rupture. All patients in whom the arthroscopic repair failed had at least 3 anchors. We do not believe that the addition of more anchors in some of these patients would have decreased the recurrence rate because we observed that the use of a mean of 3 anchors or more gave a failure rate of about 7% in the Bankart group, which was equivalent to the failure rate in the study by Boileau et al. Habermeyer et al.2 evaluated the evolution of intraarticular disease in post-traumatic shoulder instability using arthroscopy. They concluded that recurrences progressively damage stabilizing structures. They did not, however, correlate high recurrences specifically with the development of an ALPSA lesion. Spatschil et al.,38 in a prospective multicenter study, evaluated intra-articular lesions in glenohumeral instability and correlated these with clinical findings. However, ALPSA and Bankart lesions were grouped together in their study, thus confirming the findings of Habermeyer et al. They suggested that early surgical stabilization after post-traumatic anterior-inferior shoulder dislocations should be recommended to prevent increasing damage within the shoulder joint. However, in both studies, the authors did not consider patients’ anatomic and clinical outcomes. Thus, it was not possible to draw conclusions about the therapeutic implications of their study. Yiannakopoulos et al.39 showed in a recent study that 78% of patients with acute dislocation had Bankart lesions whereas 97% of patients with recurrent (chronic) dislocations had either Bankart or ALPSA lesions. All patients with ALPSA lesions were found in the chronic group. It was observed in this study that the number of shoulder dislocations was significantly higher in patients who presented with ALPSA lesions versus those who had Bankart lesions. Thus we agree with Habermeyer et al.,2 who suggested that an ALPSA lesion is the recurrence-dependent evolution of a Bankart lesion during progressive instability. We would postulate that progressive damage to the capsule and labrum results in loss of the normal robust capsulolabral structure over time. Therefore the result of repair of this
tissue, though having the appearance of a Bankarttype repair, is weaker than that with repair of less damaged capsulolabral tissue in the case of a classic Bankart lesion. Alternative surgical treatment including open capsulolabral repair or the addition of an anterior glenoid bony block to compensate for the poor-quality tissues should be considered.24,25 There are a number of limitations to this study. First, it is a retrospective study, and as with any other retrospective study, it is based on observations of outcome in a case series of patients who had certain injury and on whom specific surgery was performed. The outcome results are not statistically as powerful as those of a prospective randomized study. Second, when the 2 groups in this review are compared, the number of shoulders with simple Bankart lesions (67 shoulders) is much higher than the number with ALPSA lesions (26 shoulders). The difference in number between the 2 groups decreases the strength of the statistical analysis. Third, in a good number of patients presented in this series, the follow-up was only 2 years. A longer follow-up may show different results than those presented in this report, and thus the results of this study should be considered short-term to midterm outcomes. CONCLUSIONS Patients with ALPSA lesions present with a higher number of recurrent dislocations than those with discrete Bankart lesions. According to the results of this study, the recurrence of instability after arthroscopic capsulolabral repair for an ALPSA lesion is twice as high as the recurrence after repair of a classic Bankart lesion. REFERENCES 1. Bigliani LU, Pollock RG, Soslowsky LJ, Flatow EL, Pawluk RJ, Mow VC. Tensile properties of the inferior glenohumeral ligament. J Orthop Res 1992;10:187-197. 2. Habermeyer P, Gleyze P, Rickert M. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: A prospective study. J Shoulder Elbow Surg 1999;8:66-74. 3. Hintermann B, Gachter A. Arthroscopic findings after shoulder dislocation. Am J Sports Med 1995;23:545-551. 4. Speer KP, Deng X, Borrero S, Torzilli PA, Altchek DA, Warren RF. Biomechanical evaluation of a simulated Bankart lesion. J Bone Joint Surg Am 1994;76:1819-1826. 5. Turkel SJ, Panio MW, Marshall JL, Girgis FG. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am 1981;63:1208-1217. 6. Baker CL, Uribe JW, Whitman C. Arthroscopic evaluation of acute initial anterior shoulder dislocations. Am J Sports Med 1990;18:25-28.
RESULTS OF ARTHROSCOPIC CAPSULOLABRAL REPAIR 7. Neviaser TJ. The anterior labroligamentous periosteal sleeve avulsion lesion: A cause of anterior instability of the shoulder. Arthroscopy 1993;9:17-21. 8. Cole BJ, L’Insalata J, Irrgang J, Warner JJ. Comparison of arthroscopic and open anterior shoulder stabilization. A two to six-year follow-up study. J Bone Joint Surg Am 2000;82: 1108-1114. 9. Jobe FW, Giangarra CE, Kvitne RS, Glousman RE. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 1991;19:428-434. 10. 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;24:144148. 11. Kim SH, Ha KI. Bankart repair in traumatic anterior shoulder instability: Open versus arthroscopic technique. Arthroscopy 2002;18:755-763. 12. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: A long-term end-result study. J Bone Joint Surg Am 1978;60: 1-16. 13. Wolf EM. Arthroscopic capsulolabral repair using suture anchors. Orthop Clin North Am 1993;24:59-69. 14. 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. 15. Jorgensen U, Svend-Hansen H, Bak K, Pedersen I. Recurrent post-traumatic anterior shoulder dislocation-open versus arthroscopic repair. Knee Surg Sports Traumatol Arthrosc 1999; 7:118-24. 16. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic treatment of multidirectional shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 1997;13: 418-425. 17. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic treatment of posterior shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 1997;13:426-432. 18. Savoie FH III, Miller CD, Field LD. Arthroscopic reconstruction of traumatic anterior instability of the shoulder: The Caspari technique. Arthroscopy 1997;13:201-209. 19. Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy 2000;16:677694. 20. Grana WA, Buckley PD, Yates CK. Arthroscopic Bankart suture repair. Am J Sports Med 1993;21:348-353. 21. Laurencin CT, Stephens S, Warren RF, Altchek DW. Arthroscopic Bankart repair using a degradable tack. A followup study using optimized indications. Clin Orthop Relat Res 1996:132-137. 22. Pagnani MJ, Warren RF, Altchek DW, Wickiewicz TL, Anderson AF. Arthroscopic shoulder stabilization using transglenoid sutures. A four-year minimum followup. Am J Sports Med 1996;24:459-467. 23. Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S.
24. 25. 26. 27.
28. 29. 30.
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34. 35. 36.
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38.
39.
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