Suture Anchors Are Superior to Transglenoid Sutures in Arthroscopic Shoulder Stabilization

Suture Anchors Are Superior to Transglenoid Sutures in Arthroscopic Shoulder Stabilization Dirk P. H. van Oostveen, M.D., Ferry J. A. Schild, M.D., Michiel J. van Haeff, M.D., and Daniël B. F. Saris, M.D., Ph.D.

Purpose: We retrospectively compared 2 groups of high-demand patients with post-traumatic anterior shoulder instability to determine whether arthroscopic stabilization was superior with transglenoid suture or suture anchors. Methods: In a retrospective comparative study we investigated the results of 246 high-demand patients, with post-traumatic anterior shoulder instability, who underwent arthroscopic capsulolabral reconstruction: 165 (mean age, 27.5 years; mean follow-up, 80 months) were evaluated after treatment with transglenoid sutures, and 81 (mean age, 26.6 years; mean follow-up, 27 months) were treated with suture anchors in a consecutive period. We compared both techniques with regard to recurrence rate, postoperative complications, range of motion, sport activity, work, and patient satisfaction. Results: In the anchor group recurrent dislocation after surgery occurred in 7 patients (8.7%), all within 18 months postoperatively. This finding was significantly (P ⫽ .009) better than that in the transglenoid group, in which recurrent postoperative dislocation occurred in 57 patients (34%), in a period of 0 to 115 months after surgery. Postoperative complications were seen in 4 of 81 patients in the suture anchor group, whereas a significantly (P ⫽ .01) higher rate was found in the transglenoid suture group, with 36 complications in 35 of 165 patients. Conclusions: The data presented in this study suggest that the modern suture anchor technique results in a better outcome after shoulder stabilization, with fewer complications and lower recurrence rates, than the transglenoid repair. We conclude that the suture anchor technique should be a preferred method for arthroscopic shoulder stabilization surgery. Level of Evidence: Level III, retrospective, comparative therapeutic study. Key Words: Arthroscopy—Suture anchor—Transglenoid—Shoulder stabilization—Bankart—Capsulolabral repair.

T

he overall incidence of shoulder dislocation is approximately 11 to 17 in 100,000 persons per year.1,2 The anterior dislocation is by far most commonly seen (85%).3 Various treatment options exist that provide a considerable variation in results. Traditionally, the open surgical repair is considered the

From the Department of Orthopaedics, University Medical Center Utrecht (D.v.O, F.S., D.S.); and Central Military Hospital (M.v.H., D.S.), Utrecht, The Netherlands. D.B.F.S. is supported by the Netherlands Organization for Health Research and Development. Address correspondence and reprint requests to Daniël B. F. Saris, M.D., Ph.D., Department of Orthopaedics, University Medical Center Utrecht, Postbus 8550, 3508 GA Utrecht, The Netherlands. E-mail: [email protected] © 2006 by the Arthroscopy Association of North America 0749-8063/06/2212-5345$32.00/0 doi:10.1016/j.arthro.2006.07.006

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gold standard of treatment, because of good results in terms of recurrence rates (0% to 7%).4-6 As a result of innovations in the past decades, the arthroscopic capsulolabral repair has gained recognition. This technique has many advantages that make it worthwhile to explore as the first choice of treatment in selected patient populations.7 The most important downside to the arthroscopic technique is the reported recurrence rate, which is still higher compared with the open repair.5,8-13 Different variants of the arthroscopic technique are applied, and all techniques have a broad range of published recurrence rates.5,14 Publications on the transglenoid suture technique describe a failure rate ranging from 0% to 49%.5,6,11,14-17 In selected centers the transglenoid technique is still applied. The outcome is far inferior to that of the modern intra-articular repair via suture anchors.18 More com-

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 22, No 12 (December), 2006: pp 1290-1297

SUTURE ANCHORS VERSUS TRANSGLENOID SUTURES monly applied is the suture anchor technique, with a failure rate of 3.5% to 14%.8,14,19-24 However, the studies referred to previously have either compared the arthroscopic procedure with the open repair or focused on 1 single arthroscopic technique. Only Kandziora et al.14 compared both transglenoid and nonabsorbable suture anchor techniques, with shorter follow-up and smaller patient numbers. The results slightly favor the suture anchor technique, but the recurrence rate is unacceptably high compared with current standards. This suggests that other technical and patient-related factors are influencing the results in their study. At the University Medical Center Utrecht and the Central Military Hospital, Utrecht, The Netherlands, we applied both the transglenoid technique and the suture anchor technique in arthroscopic shoulder stabilization procedures for high-demand patients with anterior shoulder instability. Our hypothesis was that the intra-articular suture anchor technique would provide better results compared with the transglenoid technique in terms of recurrence rate, postoperative complications, range of motion (ROM), sport activity, work, and patient satisfaction. To test this hypothesis, we performed a retrospective comparative study of these arthroscopic techniques. METHODS For this investigation, we only included patients with a history of recurrent anterior shoulder instability. General exclusion criteria for the arthroscopic repair were in accordance with those in the literature: (1) children were excluded from the procedure,25,26 and (2) significant additional lesions in the shoulder were not allowed (substantial Hill-Sachs lesions, glenoid defects, or rotator cuff tears).8,21,26-28 Between August 1994 and October 2003, 267 patients underwent an arthroscopic shoulder stabilization, either at our academic hospital or at the adjacent military hospital. Between 1994 and the beginning of 2002, the transglenoid suture technique was used for stabilization. From 1998 onward, we started to use suture anchors, gradually replacing the transglenoid method as the arthroscopic procedure of first choice. Selection for both arthroscopic techniques was identical. The operations were performed by 2 experienced surgeons (M.J.v.H. and D.B.F.S.). Postoperative treatment was identical. In accordance with the literature, we used the following inclusion and exclusion criteria: (1) patients with a previous shoulder stabilization operation were excluded, (2) only cases of traumatic anterior-inferior

TABLE 1.

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Demographic Characteristics Procedure

Characteristics Gender Male Female Mean age at operation (y) (minimum-maximum) Mean follow-up (mo) (minimum-maximum)* Military occupation

Transglenoid Suture (n ⫽ 165)

Suture Anchor (n ⫽ 81)

131 (79%) 34 (21%)

70 (86%) 11 (14%)

27.5 (17-47)

26.6 (18-46)

58 (0-124) 99 (60%)

27 (2-82) 53 (65%)

NOTE. Groups are comparable and correspond to literature on operative shoulder stabilization. The main difference is the length of follow-up, which is much longer for the transglenoid group. *Follow-up ends when dislocation occurs or at end of study.

shoulder instability were included, and (3) patients had to have undergone surgery at least 1 year before the start of the research. Of the 267 patients who underwent surgery for this indication at our hospitals, 246 met the inclusion criteria. The transglenoid suture group consisted of 165 patients, and the anchor group consisted of 81 patients. As demonstrated in Table 1 and Fig 1, the demographic characteristics did not differ between groups. A characteristic of special importance for this research is the number of patients who work in military services, because these patients are physically more active and include a rather large percentage of very high-demand overhead athletes. The mean interval between operation and evaluation was 81 months for the transglenoid suture patients, as compared with 28 months for the suture anchor group. Outcome was evaluated by use of the following methods: Patient charts were investigated in search of preoperative diagnosis, postoperative complications, and recurrent dislocation or reoperation. A questionnaire was used, one part of which contained questions about recurrent dislocation or subluxation and the date of this event. Further questions focused on activities in sports and work. A visual analog scale was used to determine subjective patient satisfaction. To investigate the general functionality of the shoulder, we used the Dutch language–validated version of the Simple Shoulder Test.29 If patients did not return the questionnaire after being reminded to do so, an inquiry by phone on recurrent dislocation and reoperation was added. The most important outcome parameter was a possible recurrence of instability. In the case of subluxa-

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50%

Sutu re an ch ors

were analyzed by use of SPSS software (release 12.0.01; SPSS, Chicago, IL).

T ra ns gle no id su ture s

General Description of Operative Techniques

Percent

40%

30%

20%

10%

0% 20- yrs

20-25 yrs 25-30 yrs 30-35 y rs 35-40 yrs' 40+ yrs

age at operation

FIGURE 1. Age at operation in suture anchor group (black bars) and transglenoid suture group (hatched bars). Differences were not statistically significant, with a mean age around 27 years and small numbers of patients aged over 40 years. These data are comparable to those of other groups in the literature reporting results of operative shoulder stabilization.

tion or dislocation being found on medical charts or through the questionnaire, the date of dislocation marked the end of follow-up. Otherwise, the date of completion of the questionnaire was used to compute the follow-up data. The follow-up for the few nonresponders is calculated until the last contact at the outpatient clinic (Table 2). For the results with regard to ROM, work, sporting activities, and satisfaction, we were able to discern a subgroup of patients who were reoperated on after their inclusion into our research study. Because their response reflects the result of a combination of various operations. This group consists of 39 patients: 3 from the original suture anchor group and 36 from the original transglenoid suture group.

For the arthroscopic techniques, the aim was labral refixation combined with a capsular shift. Both procedures started with an examination with the patient under anesthesia. Surgery was performed with the patient in the lateral decubitus position by use of longitudinal and lateral traction on the affected arm. The joint was inspected by arthroscopy, to find any bony, labral, or ligamentous defects. The affected tissue was mobilized for anatomic reduction of the labrum. The anterior glenoid rim was decorticated with a rasp and motorized shaver. After these preparations, one of the following suture techniques was applied to perform the superior shift of the labral-ligamentous complex. Capsulolabral Fixation With Transglenoid Sutures: A suture pin was passed through the detached capsulolabral complex.30 Thereafter the pin was drilled through the glenoid rim, emerging approximately 5 cm inferior to the scapular spine. By use of an aiming device, a second parallel suture pin was drilled through the glenoid, starting at some distance from the first pin location. In this manner, the labrum can be reattached onto the rim of the glenoid, in the anteroinferior area. In incidental cases a third hole was added. With the arm in 0° of external rotation, the PDS No. 1 sutures (Ethicon, Somerville, NJ) were then tied to themselves over the fascia of the infraspinatus muscle. Suture Anchor Technique: Before the introduction of bioabsorbable anchors in 2001, we used FASTak titanium anchors (Arthrex, Naples, FL). From March 2001 onward, we used absorbable BioFASTak anchors (Arthrex). The anchor is made of poly-L-lactic acid, with one No. 2 FiberWire suture (Arthrex). After the general procedure as described previously, a threaded TABLE 2.

Procedure

Data Analysis To statistically test the hypothesized difference in recurrence of instability, survival analysis was performed by use of a Kaplan-Meier curve. Statistical significance was calculated by applying a log-rank test. For other parameters, the ␹2 test was used to analyze nominal variables and the Student t test was used to compare means of interval or ratio variables. A level of significance of P ⬍ .05 was used. All data

Patient Response

Response

Transglenoid Suture (n ⫽ 165)

Suture Anchor (n ⫽ 81)

Total (n ⫽ 246)

Questionnaire Telephone Dislocation in chart No response

140 10 4 11

74 4 0 3

212 (86%) 14 (6%) 4 (2%) 14 (6%)

NOTE. Patient response was comparable in both groups. The total response rate was 94%.

SUTURE ANCHORS VERSUS TRANSGLENOID SUTURES

1,0

0,8

Cumulative Survival

pilot hole was made 2 to 3 mm over the rim onto the glenoid surface. The anchor was then inserted and screwed into the pilot hole. Once the anchor was properly seated, the suture was passed through the capsule and ligaments, underneath the labrum. A fisherman’s knot was tied arthroscopically by use of a knot pusher. Additional alternating post half-hitch knots were used to secure the fixation. A second anchor was used in a similar fashion. Depending on the extent of the lesion, additional anchors could be placed approximately 0.5 to 1.5 cm from the previous anchor. In all cases a minimum of 2 anchors were used to fix the capsulolabral complex.

1293

0,6

0,4

0,2

Suture ancho rs Transglen oid sutu res

0,0

0

25

50

75

100

125

follow-up recu rren t dislo catio n (m o nth s)

Postoperative Treatment Postoperative care of the patients consists of immobilization during a 4-week period. During this time, active circumduction exercises in a neutral position were gradually started to prevent shoulder stiffness. External rotation of the shoulder beyond 0° was avoided, as was abduction beyond 30°. After 2 weeks, physiotherapeutic supervised training of the hand and elbow was initiated. Between 7 and 10 weeks after surgery, the normal ROM could be reached. During the postoperative period, an outpatient follow-up visit took place at 3 weeks, 3 months, and if necessary, 6 months.

TABLE 3.

FIGURE 2. Kaplan-Meier curve comparing dislocation recurrence after repair with suture anchors (7/81 patients, all within 18 months) (black marks) and with transglenoid sutures (57/165 patients, period spreads to ⬎10 years after operation) (gray marks). There is a strong statistical difference in favor of suture anchor fixation.

RESULTS Response and Follow-Up The response to our request for data is outlined in Table 2. The response rates are equally spread over both groups. As the cohorts comprised techniques used in 2 consecutive periods of time, the mean follow-up of the transglenoid suture patients is substantially longer than that of the suture anchor group (Table 1).

Recurrence and Postoperative Complications

Recurrence and Postoperative Complications

Procedure Complication Dislocation Recurrent dislocation Recurrent subluxation No dislocation Frozen shoulder Temporary limited external rotation Suture problems Nerve injury (suprascapular) Persisting pain Complex regional pain syndrome Total complications

Transglenoid Suture (n ⫽ 165)

Suture Anchor (n ⫽ 81)

57 (34.5%) 30 (18.2%) 78 (47.3%) 19 (11.5%)

7 (8.6%) 19 (23.5%) 55 (68.0%) 3 (3.7%)

2 (1.2%) 6 (3.6%)

0 (0%) Not applicable

5 (3.0%) 3 (1.8%)

Not applicable 1 (1.5%)

1 (0.6%) 36 (21.8%)

0 (0%) 4 (6.2%)

NOTE. Recurrent dislocation and all other complications occurred more often in the transglenoid suture group.

The difference in the incidence of recurrent dislocation between the 2 groups is clearly demonstrated in Table 3: 7 of 81 patients in the suture anchor group had at least 1 dislocation after the operation, as compared with 57 of 165 in the transglenoid suture group (power, 0.98). The Kaplan-Meier survival curve displayed in Fig 2 demonstrates this difference graphically. When these differences were analyzed with log-rank statistics, the results of the suture anchors were significantly better (P ⫽ .009). From the Kaplan-Meier curve, we can also deduce that recurrent instability in the suture anchor group did not occur past an interval of 18 months after surgery. The curve of the transglenoid suture group begins with a steep decline in survival rate, which gradually levels, but recurrence even occurs 10 years after the operation. If we take into account the learning curve for

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0,8

Cumu lative Frequ enc y

25

0,6

0,4

5

spontaneous sport trauma unknown

20

15

10

Suture anchor

0 120 108 102 96 90 72 60 54 48 42 36 30 24 18 12 6 Follo w-up div ide d in s trata (months)

0

20

40

60

80

100

120

fo llo w -up recurrent d islocation (m onths)

FIGURE 3. Kaplan-Meier curve with learning curve taken into account: The first 30 arthroscopically operated patients were excluded. These were all part of the transglenoid group. The follow-up of this group is now under 10 years. No significant difference is seen compared with Fig 2. The difference between the suture anchor technique (black marks) and the transglenoid suture technique (gray marks) remains statistically significant.

arthroscopic surgery, by leaving out the first 30 arthroscopic shoulder stabilization cases, the KaplanMeier curve shows the same tendency (Fig 3) and both statistics and power remain unchanged. When patients were divided into those with an

A

B

50%

Civilian

80%

Civilian

M ilitary

Military 40%

30%

Percent

Percent

60%

40%

20%

20%

10%

0%

3

2

0

Transglenoid s uture 0,0

spontaneous sport trauma

1

5

0,2

4 Cumulative Frequency

30

Cumulative Survival

B

A

1,0

6 12 1 8 30 36 42 48 54 60 66 72 78 84 Follow-up divided in strata (months)

FIGURE 5. (A) Recurrent dislocation causes in transglenoid suture group. Spontaneous dislocation is the leading cause, especially after 5 years. (B) Recurrent dislocation causes in suture anchor group. Dislocation is limited to the first 18 months, mainly caused by an adequate trauma. (squares, spontaneous; triangles, sport; plus signs, trauma; circles, unknown.)

occupation in the military and civilians, there was a 12% to 17% higher rate of recurrent instability in the military group (Fig 4). The mechanism of recurrence was categorized by cause as spontaneous, sports, or traumatic. Fig 5 shows that the cause of recurrent dislocation differs between the groups. There was a higher rate of spontaneous recurrence in the transglenoid suture patients, whereas recurrence in the suture anchor group was merely a result of adequate trauma. The postoperative course of the transglenoid technique is inferior with regard to both the number and severity of complications (Table 3). The total number of postoperative complications was significantly higher in the transglenoid suture group (P ⫽ .01). Most frequently found was frozen shoulder, which had a lower rate of occurrence in the suture anchor group (P ⫽ .057). Notorious for the transglenoid technique is the nervus suprascapularis lesion. In our study we had 2 patients with nervus suprascapularis neurapraxia. Also involved in this technique is the risk of infection of the transglenoid suture on the dorsal skin (n ⫽ 6).

0%

no recurrence

recurrent recurrent dislocation subluxation

no recurrence

recurrent recurrent dislocation subluxation

FIGURE 4. (A) Recurrence in transglenoid suture group with patients divided into civilians (n ⫽ 66) (black bars) and those in the military (n ⫽ 99) (hatched bars). The rate of recurrence is high, and recurrence occurs in both groups. Recurrent dislocation is more evident in high-demand patients. (B) Recurrence in suture anchor group with patients divided into civilians (n ⫽ 28) (black bars) and those in the military (n ⫽ 53) (hatched bars). Recurrent dislocation and subluxation occur in a minority of patients and are observed more frequently in the high-demand group.

Consequences Regarding Daily Life Focusing on ROM, our standardized questionnaire contained some questions that gave an indication of external and internal rotational extension. As an example regarding external rotation, Table 4 shows the response in the ability to throw a ball. A total of 22 patients had pain at rest in the affected shoulder, with a relatively high percentage in the

SUTURE ANCHORS VERSUS TRANSGLENOID SUTURES TABLE 4.

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ROM, Pain, Work and Sporting Activities Procedure

Responders to items Throwing tennis ball ⬎20 m Pain at rest Change in working activities Change in type of sport Improvement Aggravation Change in level of sport Improvement Aggravation Patient satisfaction (SD)

Transglenoid Suture

Suture Anchor

Reoperated Patients

113/129 60 (55%) 15 (13%) 17 (15%)

70/78 47 (67%) 5 (7%) 13 (19%)

34/39 20 (59%) 2 (6%) 7 (21%)

7 (6%) 39 (35%)

2 (3%) 19 (27%)

0 (0%) 14 (41%)

12 (11%) 49 (43%) 7.6 (2.5)

8 (11%) 23 (33%) 7.8 (2.5)

0 (0%) 20 (59%) 5.5 (3.4)

NOTE. Patients who were reoperated on (either in an open manner or arthroscopically) after their initial inclusion were analyzed separately. Shoulder function is slightly better after suture anchor repair, as compared with the transglenoid repair. Reoperated patients scored poorly on all items.

transglenoid group (Table 4). Table 4 demonstrates that there was no substantial difference between the 2 operating techniques with regard to change in work as a result of the operation(s). As also shown in Table 4, there was a shift in type of sporting activities to a lower degree of throwing and contact sports. The level of sporting activities also changed. Within the subgroup of reoperated patients, most continued at a lower level or discontinued sporting activities, whereas most patients treated with suture anchors could continue at their preoperative level. To investigate patient satisfaction, we used a 10point visual analog scale. The differences in satisfaction between the groups were minor if reoperated patients were excluded from both groups (Table 4). As explained earlier, a separate group of reoperated patients was formed, because their response is not a true reflection of the initial arthroscopic operation. DISCUSSION This investigation demonstrates a better result after arthroscopic shoulder stabilization with a suture anchor technique compared with the transglenoid suture method with regard to the recurrent dislocation rate (8.6% v 34.5%, P ⫽ .009). In addition, there were fewer postoperative complications (5% v 22%, P ⫽ .01). Because the effect of a learning curve for arthroscopic shoulder procedures is emphasized,14 an additional analysis was performed (Fig 3). The differences in rates of recurrent dislocation remained unchanged in this situation (P ⫽ .006), and this does not change

the conclusion with regard to differences in postoperative complications. Although postoperative treatment did not change in essence, the immobilization period decreased from 6 to 4 weeks through the years. This earlier mobilization might partially explain the lower incidence of frozen shoulder in the suture anchor group. As shown in Table 3, the rate of subluxation in the suture anchor group exceeds that in the transglenoid suture group by 5%. In addition, the total instability rate (recurrent dislocation and subluxation) for both techniques is substantial compared with the meta-analysis of Freedman et al.5 The main reason for the higher total instability rate in our study might be the long duration of follow-up. This is supported by recent studies with comparable follow-up that found total instability rates of up to 60% for transglenoid sutures.11,31 Another explanation is that in military patients a limited capsular shift was performed: in these cases recurrent instability with the possibility of performing reoperation for a further capsular shift is preferred above the risk of a stiff shoulder, which would be a likely cause of discharge from military service. This is one of the confounding factors contributing to the inferior outcome of the military patients (Fig 4). Strength and Limitations of Research Design The strength of our research in comparison to that of other investigators is the large number of patients in combination with the long follow-up, especially for the transglenoid suture group. With respect to physical activity, our population can be classified as “high

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demand.” This justifies a comparison of results with investigations in contact and overhead athletes. Although the results appear convincing, the cohort design incorporates a weakness: because of the retrospective study design, no randomization was possible. Another limitation is a significant difference in the duration of follow-up. However, this effect is neutralized by the Kaplan-Meier curve, displaying the survival time until recurrent dislocation. Because patient selection criteria did not change during the entire research period, both cohorts are very similar with regard to demographic characteristics (Table 1) and correspond to characteristics from the literature.5 Patient results have been partially acquired by a questionnaire, without an examination of the patients being performed on the final date of follow-up. However, the most important parameters have been observed or registered (or both) at the outpatient clinic in the majority of cases, either during the regular postoperative follow-up visit or when the patient had problems at a later stage. Various publications on arthroscopic shoulder stabilization plead for a minimum follow-up of 18 to 24 months also, because this seems to be a critical limit beyond which recurrent dislocation would not occur.5,14,16,29 The suture anchor survival curve (Fig 2) supports this idea. If we analyze the suture anchor group with a minimum postoperative interval of 18 months (n ⫽ 71) or 24 months (n ⫽ 52), the recurrent dislocation differences are still statistically significant (P ⫽ .01). Finally, the 2 different operating surgeons might be a limiting factor in comparing results. However, there was no significant difference found between the 2 surgeons with regard to recurrence rate and complications. Comparison to Literature The results with suture anchors are similar to or better than those of most previous publications in similar groups with equal or smaller numbers of patients.14,17,20 However, better results in either smaller or more selected groups were described by Barber et al.,21 Ide et al.,23 and Kim et al.19 Still, a recurrence rate of 8.6% for the suture anchor technique is not equal to that for open Bankart repairs, even in most high-demand groups.32 Therefore the choice regarding an arthroscopic procedure has to be based on characteristics such as ROM, decreased chance for osteoarthritis, postoperative pain, and morbidity, as mentioned at the beginning of this report. The literature is contradictory with regard to the course of recurrence. There are several reports in

which recurrence is limited to the first 2 postoperative years.5,14,16 Our findings in the suture anchor group support these figures. On the other hand, Steinbeck and Jerosch13 and Torchia et al.31 found a high percentage of recurrence after more than 2 years, especially in a very active population. This corresponds to our results in the transglenoid suture patients, in whom recurrence occurs during the entire follow-up period. A definite answer with regard to the recurrent dislocation period cannot be concluded from our data. There are several theoretic arguments to support the different results of the two techniques. The suture anchor method has a biomechanical advantage.33,34 Furthermore, the transglenoid technique accomplishes bidirectional labral fixation, where the suture anchors lead to anatomic repositioning. The fact that transglenoid sutures are fixed on a dynamic basis is important as well. There is evidence that the underlying infraspinatus muscle atrophy causes a decrease in tension on the labrum.31 The suture material might also play a role, because the PDS sutures (Ethicon) used in the transglenoid technique dissolve after 10 to 12 weeks whereas the bioabsorbable anchors have a 36-week degrading period. There were 2 patients with an irreversible postoperative complication: a suprascapular nerve lesion (1.2%). This finding corresponds with the incidence of 0% to 6% reported in the literature.4,14,17,25,35,36

CONCLUSIONS In patients with anterior shoulder instability, arthroscopic shoulder stabilization is an effective surgical technique for a selected group. This study indicates the superiority of the suture anchor technique, which showed significantly better results in terms of recurrent postoperative dislocations (8.6% v 34.55%) and postoperative complications, as compared with the transglenoid suture technique. In this study the suture anchor method has a recurrent dislocation period that seems to be limited to 18 months, whereas dislocations in patients undergoing the transglenoid technique can occur even after many years. On the basis of this study and comparison to data from the literature, we suggest that the all-inside suture anchor repair should be used as the technique of choice for arthroscopic shoulder stabilization surgery. Acknowledgments: We would like to thank the Department of Physiotherapy and the Medical Archive Department of the Central Military Hospital, Utrecht, for their co-operation on data acquisition.

SUTURE ANCHORS VERSUS TRANSGLENOID SUTURES REFERENCES 1. Kroner K, Lind T, Jensen J. The epidemiology of shoulder dislocations. Arch Orthop Trauma Surg 1989;108:288-290. 2. Simonet WT, Melton LJI, Cofield RH, Ilstrup DM. Incidence of anterior shoulder dislocation in Olmsted County, Minnesota. Clin Orthop Relat Res 1984:186-191. 3. Rockwood CA, Matsen FA. In: Rockwood, CA, Matsen FA, eds. The shoulder. Ed 2. Philadelphia: Saunders, 1998;611754. 4. Bankart ASB. The pathology and treatment of recurrent dislocation of the shoulder-joint. Br J Surg 1938;26:23-29. 5. Freedman KB, Smith AP, Romeo AA, Cole BJ, Bach BR Jr. Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for recurrent anterior instability of the shoulder: A meta-analysis. Am J Sports Med 2004;32:1520-1527. 6. Rowe CR, Patel D, Southmayd WW. The Bankart procedure: A long-term end-result study. J Bone Joint Surg Am 1978;60: 1-16. 7. Hill JA, Lombardo SJ, Kerlan RK, et al. The modification Bristow-Helfet procedure for recurrent anterior shoulder subluxations and dislocations. Am J Sports Med 1981;9: 283-287. 8. 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;20:456-462. 9. Green MR, Christensen KP. Arthroscopic versus open Bankart procedures: A comparison of early morbidity and complications. Arthroscopy 1993;9:371-374. 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. Hubbell JD, Ahmad S, Bezenoff LS, Fond J, Pettrone FA. Comparison of shoulder stabilization using arthroscopic transglenoid sutures versus open capsulolabral repairs: A 5-year minimum follow-up. Am J Sports Med 2004;32:650654. 12. Karlsson J, Magnusson L, Ejerhed L, Hultenheim I, Lundin O, Kartus J. Comparison of open and arthroscopic stabilization for recurrent shoulder dislocation in patients with a Bankart lesion. Am J Sports Med 2001;29:538-542. 13. Steinbeck J, Jerosch J. Arthroscopic transglenoid stabilization versus open anchor suturing in traumatic anterior instability of the shoulder. Am J Sports Med 1998;26:373-378. 14. 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. 15. Morgan CD, Bodenstab AB. Arthroscopic Bankart suture repair: Technique and early results. Arthroscopy 1987;3:111122. 16. Walch G, Boileau P, Levigne C, Mandrino A, Neyret P, Donell S. Arthroscopic stabilization for recurrent anterior shoulder dislocation: Results of 59 cases. Arthroscopy 1995;11:173179. 17. Boszotta H, Helperstorfer W. Arthroscopic transglenoid suture

18.

19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

30. 31. 32.

33. 34. 35.

36.

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