- Email: [email protected]
The Rationale for an Arthroscopic Approach to Shoulder Stabilization
Current Concepts With Video Illustration
The Rationale for an Arthroscopic Approach to Shoulder Stabilization Fotios P. Tjoumakaris, M.D., and James P. Bradley, M.D.
Abstract: The gold standard of treatment for glenohumeral instability has traditionally been viewed as open shoulder stabilization. With the increased awareness of complex instability patterns and the ability to preoperatively detect concomitant pathology with advanced imaging modalities, an evidence-based shift to an all-arthroscopic approach to shoulder stabilization surgery is occurring. Current data suggest that patients who meet eligibility criteria for arthroscopic stabilization (those without significant bony lesions or significant deformity) can expect equivalent rates of recurrence, better functional outcomes, and less morbidity. Modern arthroscopic techniques using suture anchors and capsular plication have resulted in a significant improvement over previous reports in the orthopaedic literature. An argument is put forth on the benefits of an all-arthroscopic approach to shoulder stabilization in athletes and nonathletes alike based on a review of the current orthopaedic literature comparing the evolved arthroscopic technique with more traditional open methods.
A
rthroscopic shoulder stabilization for recurrent glenohumeral instability has evolved considerably over the past 2 decades. Advantages of an allarthroscopic technique are numerous, ranging from preservation of the subscapularis to the ability to address a multitude of concomitant pathologies. In addition, arthroscopic stabilization can potentially provide more favorable range of motion and early return
From the Department of Orthopaedic Surgery, Rothman Institute Orthopaedics, Thomas Jefferson University (F.P.T.), Philadelphia; Department of Orthopaedic Surgery, University of Pittsburgh Medical Center (J.P.B.), Pittsburgh; Pittsburgh Steelers (J.P.B.), Pittsburgh; and Burke and Bradley Orthopaedics (J.P.B.), Pittsburgh, Pennsylvania, U.S.A. J.P.B. receives royalties and research grants from Arthrex. The authors report no conflict of interest. Received November 12, 2010; accepted June 3, 2011. Address correspondence to James P. Bradley, M.D., Burke and Bradley Orthopaedics, 200 Delafield Rd, Ste 4010, Pittsburgh, PA 15215, U.S.A. E-mail: [email protected] © 2011 by the Arthroscopy Association of North America 0749-8063/10683/$36.00 doi:10.1016/j.arthro.2011.06.006 Note: To access the video accompanying this report, visit the October issue of Arthroscopy at www.arthroscopyjournal.org.
1422
to full functional activity in high-demand patients.1 Despite these advantages, widespread acceptance of an all-arthroscopic approach to shoulder instability among members of the orthopaedic community is lacking, partly because of the high failure rate that was reported in early studies on recurrent anterior instability.2-4 Modern suture anchor devices combined with a trend away from transglenoid sutures and metallic staples have been responsible for a great deal of success in more recent studies. In addition to these technical advancements, our understanding of the multifactorial etiology of glenohumeral instability and our ability to recognize complex injury patterns with advanced imaging modalities have led to a tailored approach to the patient with recurrent shoulder instability. Shoulder instability can range in severity from a subluxation event to a dislocation of the glenohumeral articulation. The direction of instability can be classified as anterior, posterior, or multidirectional, and patients may have recurrence of symptoms after significant trauma (i.e., collision) or relatively atraumatic events (i.e., activities of daily living). Very minimal symptoms and physical signs can often be accompanied by significant findings with magnetic resonance
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 10 (October), 2011: pp 1422-1433
ARTHROSCOPIC SHOULDER STABILIZATION imaging and arthroscopic visualization even in the absence of frank dislocation.5 Historical classification systems attempt to simplify the injury pattern into traumatic versus atraumatic, direction (anterior/posterior), and chronicity; however, patients may present anywhere along this spectrum and may require a more complex surgical management algorithm when operative intervention is indicated. In the following discussion we will review the use of modern arthroscopic techniques for the treatment of simple and complex instability patterns of the shoulder. The justification for evolving from an open surgical technique to an all-arthroscopic approach for shoulder stabilization will be analyzed from a review of current literature and a comparison of similar techniques. Through this analysis, it is our hope to clearly define the indications and make a case for an allarthroscopic approach; in addition, we will delineate the contraindications when appropriate.
1423
FIGURE 2. Axial T2 magnetic resonance imaging scan of a right shoulder showing a Hill-Sachs lesion (asterisk) of the posterolateral humeral head.
ANTERIOR INSTABILITY Traditionally, anterior instability was thought of as a fairly simple injury pattern resulting in a dislocation of the humeral head off of the anterior glenoid rim. With advanced imaging modalities and detailed arthroscopic visualization, pathology has been recognized beyond the presence of Bankart and Hill-Sachs lesions (Figs 1 and 2). Patients with anterior instability may present with significant capsular injury ranging
from elongation and plastic deformation of the anterior capsule to capsular tearing that contributes to the instability pattern (Fig 3).6 Humeral avulsion of the glenohumeral ligament (HAGL) lesions are rare occurrences but, when present, are a significant source of morbidity.7 Rotator interval lesions (coracohumeral ligament, superior glenohumeral ligament) and SLAP tears can also be found concomitantly with other labral and ligamentous pathology and complicate this
FIGURE 1. Axial T2 magnetic resonance imaging scan of a right shoulder showing a Bankart lesion or avulsion of the inferior capsulolabral complex from the glenoid rim.
FIGURE 3. Arthroscopic view of a right shoulder from the posterior portal (lateral decubitus position) showing an anterior capsular tear in a patient with multiple failed stabilization procedures.
1424
F. P. TJOUMAKARIS AND J. P. BRADLEY
FIGURE 4. Arthroscopic view of a left shoulder from the posterior portal (lateral decubitus position) showing a Hill-Sachs lesion that engaged in late abduction/external rotation (asterisks).
instability pattern.8 Historical treatment of anterior instability has included nonoperative management such as slings and orthotics, as well as therapeutic exercises and lifestyle modification. When surgical intervention is warranted, open or arthroscopic stabilization can be considered; however, historically, open stabilization has been superior to arthroscopic treatment in this patient cohort. There are clear indications for open treatment of anterior instability. Patients with large Hill-Sachs lesions that “engage” in early abduction and external rotation have been shown to have higher recurrence rates after isolated capsulolabral reconstruction.9 The issue of whether a Hill-Sachs lesion is deemed “significant” is controversial, and some authors have reported that lesions as small as 12.5% of the humeral head diameter may cause significant biomechanical alterations.10 For our purposes, we define significant Hill-Sachs lesions as those that are likely to engage the glenoid rim in a position of function when the arm is in abduction and external rotation, as described by Burkhart and De Beer11 (Fig 4). Glenoid bone deficiency, as is the case with humeral head defects, can also significantly increase the recurrence rate after isolated capsular and labral repair. Rowe et al.9 have stated that glenoid bone defects comprising more than 30% of the glenoid were a contraindication to repair alone, and Itoi et al.12 showed that defects comprising 21% of the total glenoid length had recurrent instability and decreased motion. Arthroscopic means to address bone deficiencies of the shoulder have been
reported, and the results are encouraging13,14; however, further studies are needed to validate these techniques and their long-term effectiveness. Recently, Skendzel and Sekiya15 described a novel technique of osteoarticular arthroscopic glenoid reconstruction without violating the subscapularis. Although longterm results of all of these techniques are currently lacking, they have shown promise in addressing bone deficiency through a minimally invasive approach. Soft-tissue deficiencies, in addition to osseous deficiencies, may also necessitate an open approach, as can sometimes be seen in capsular deficiency after multiple stabilizations or when the subscapularis is torn. Revision surgery in and of itself should not be viewed as an absolute contraindication to an arthroscopic approach. Studies have shown success in restoring stability after previously failed open and arthroscopic stabilizations with more modern arthroscopic techniques.16,17 In the absence of clear contraindications, we believe that arthroscopic stabilization for anterior instability can achieve comparable results to open stabilization with modern arthroscopic techniques. Studies comparing the outcomes of open and arthroscopic techniques are numerous but warrant further analysis to determine whether the benefits of open surgery outweigh the potential complications and to determine whether they can be extrapolated to modern techniques. In a study by Hubbell et al.,18 failure occurred at a significantly higher rate in patients undergoing arthroscopic fixation compared with the open cohort (nearly 60% of patients in the arthroscopic group had symptoms of instability); however, improved stability in the open group came at a significant cost to range of motion (18° deficit in external rotation). This study used transglenoid suture fixation, which is no longer used for arthroscopic stabilization. Karlsson et al.19 performed a similar study using biodegradable tacks and found similar functional outcomes between patient cohorts; however, the failure rate was higher in the arthroscopic group (15% v 10%). These authors again found that open stabilization was associated with more significant range of motion loss (10°) (Table 1). In a meta-analysis evaluating 6 studies, Freedman et al.20 found that superior results with regard to recurrent instability (3% v 13%), total recurrence (10% v 20%), and outcome (good/excellent in 88% v 71%) were demonstrated when open surgery was compared with an arthroscopic technique. In another metaanalysis, with the inclusion of 11 studies, the only similarity observed between these 2 methods was the reoperation rate, with open stabilization showing su-
ARTHROSCOPIC SHOULDER STABILIZATION TABLE 1.
Results of “Traditional” Arthroscopic Anterior Shoulder Stabilization
Author
Year
Karlsson et al.19 Hubbell et al.18 Freedman et al.20 Total/mean
2001 2004 2004
No. of Patients
Follow-up (mo)
66 20 172 258
28 60 24* 37
Recurrence Rate 15% 17% 13% 15%
*Minimum length of follow-up for study inclusion.
periority with regard to instability and return to activity.21 Examination of these studies further, however, shows that the literature is comparing a technique that has withstood the test of time with an arthroscopic approach that was still early in its evolution and is now essentially outdated. The first meta-analysis analyzed patients who underwent transglenoid suture and tack fixation, which has fallen out of favor over the past several years. In the more recent analysis, of the initial 18 studies that were eligible for review, only 2 reported on a modern arthroscopic technique. Previous studies have fallen victim to analyzing heterogeneous patient populations with a wide array of pathologies using varied techniques with no clear definitions of success and failure. More recent studies paint a clearer picture of where an arthroscopic approach has come thus far. What precisely defines a “modern” arthroscopic technique can vary from surgeon to surgeon; however, as we attempt to standardize our approach to treatment, several principles have evolved and influenced outcomes. Three principles currently define our approach to treatment: the use of multiple suture anchors (ⱖ3), a proximal shift of the anterior capsule and capsular plication to address capsular laxity, and treatment of associated intra-articular pathologies (rotator interval lesions, SLAP tears, capsular rents). In a study by Boileau et al.,22 patients with significant inferior instability, those with anterior capsular laxity, and those in whom fewer than 4 anchor points were used were at significant risk for recurrence with a suture anchor arthroscopic approach. Studies that take these principles into account when comparing techniques offer us additional insight into our current approach for anterior instability. In the first study to evaluate a modern technique and an open procedure, Kim et al.23 found equal rates of recurrence in both groups (10%); however, the arthroscopic group had better functional outcomes at 3-year follow-up. In a follow-up to this study analyzing 167 patients, Kim et
1425
al.24 found a 4% recurrence rate with good to excellent results in 95% of patients at 2 to 6 years, with over 90% of patients returning to their previous level of sport. The mean loss of external rotation was only 2°, and recurrence was associated with glenoid deficiency in excess of 30%, in agreement with the previous report by Rowe et al.9 In a previous study, 1 of us (F.P.T.) reported on a modern arthroscopic technique using suture anchors and an open technique using identical implants.25 Patient-assessed outcomes were similar in both groups, and there was no difference in recurrence at 2-year follow-up. In a randomized controlled study, Fabbriciani et al.26 assessed outcomes in a series of patients assigned to either an arthroscopic or open approach. Sixty patients were studied and analyzed at 2-year follow-up, with no difference in recurrence rates between groups and better overall range of motion in the arthroscopic group. In a Cochrane Database systematic review evaluating randomized trials of open and arthroscopic Bankart repairs for anterior shoulder instability, the authors found no difference between the groups and could make no formal recommendations for one approach over the other.27 Critical comparisons in this study were made for recurrence of instability, reoperation on the affected shoulder, or surgery for any reason. Shoulder outcomes were also found to be similar between groups when using these rigorous study criteria. In agreement with these findings were the results of a more recent meta-analysis analyzing more modern suture anchor techniques in open and arthroscopic surgery.28 The authors found that studies done after 2002 showed significant differences in recurrence rates in favor of arthroscopy (2.9% v 9.2%). Analysis of all the data showed recurrence rates to be similar between groups (6% for arthroscopic approach v 6.7% for open approach) (Table 2). On the basis of these recent data, it is reasonable to TABLE 2.
Results of “Modern” Arthroscopic Anterior Shoulder Stabilization
Author
Year
Kim et al.23 Tjoumakaris et al.25 Fabbriciani et al.26 Pulavarti et al.27 Petrera et al.28 Total/mean
2002 2006 2004 2009 2010
No. of Patients
Follow-up (mo)
58 69 30 92 234 483
39 24* 24 24* 24* 27
*Minimum length of follow-up for study inclusion.
Recurrence Rate 10% 1% 0% 8% 6% 5%
1426
F. P. TJOUMAKARIS AND J. P. BRADLEY
FIGURE 5. Axial T2 magnetic resonance imaging scan of a right shoulder showing a posterior labral tear (asterisk).
make the assertion that the gap with regard to the recurrence of instability has closed after arthroscopic capsulolabral repair for anterior instability. Advantages of an arthroscopic repair in this patient cohort include less perioperative morbidity; fewer postoperative motion problems, obviating the need for subscapularis healing; improved strength of the subscapularis; ability to address concomitant pathology; and less postoperative pain and need for hospital admission.29-31 Range-of-motion loss in external rotation of up to 20°, as has been reported in some studies of open Bankart repair, would be particularly challenging and unacceptable for any high-demand athlete wishing to return to competitive play. As such, our current approach for recurrent anterior glenohumeral instability in all patients regardless of sport, and in the absence of the aforementioned contraindications, is to use an all-arthroscopic technique.
so on). In the past, posterior shoulder instability has presented both a diagnostic and therapeutic challenge for shoulder surgeons; however, with advanced imaging techniques and modern arthroscopic repair methods, the successful recognition and treatment of patients with this pathology are now commonplace (Figs 5 and 6). As with anterior instability, significant bone defects (reverse Hill-Sachs lesions), glenoid deficiency or retroversion, and capsular deficiencies (reverse HAGL lesions) may still warrant an open approach to treatment when they contribute to this instability pattern and have been described in the literature.34-36 A number of theories and a variety of pathologies have been reported to be the contributing cause in patients with posterior shoulder instability. Glenoid retroversion or hypoplasia, relative chondrolabral retroversion, humeral retroversion, reverse Hill-Sachs lesions, reverse Bankart lesions, rotator interval lesions, capsular attenuation and laxity, and Kim lesions have all been shown to be prevalent in patients with this instability pattern.37-40 It is typically the combination of multiple findings that predisposes the patient to recurrent posterior instability, and the treatment that is chosen must be pathology specific. It is often difficult to differentiate unidirectional posterior instability from multidirectional (posteroinferior, anterior/ posterior/inferior) instability because capsular laxity may be present in this patient population. The loadand-shift test, sulcus sign (in neutral and external
POSTERIOR INSTABILITY Posterior shoulder instability is an uncommon entity, occurring in 5% of all patients presenting with shoulder instability.32 Whereas a significant number of patients presenting with posterior shoulder instability may report trauma as the inciting cause, a number of patients may report episodes of subluxation when the arm is placed in a position of function.33 Recurrent posterior subluxation may be more common than frank posterior dislocation of the shoulder, with presenting signs and symptoms that are more vague (soreness or pain, shoulder fatigue with activity, and
FIGURE 6. Arthroscopic view of a left shoulder from the anterior portal (lateral decubitus position) showing a posterior labral tear in a patient with recurrent posterior subluxation.
ARTHROSCOPIC SHOULDER STABILIZATION TABLE 3.
Results of Open Posterior Shoulder Stabilization
Author Warren and colleagues47 Tibone and Bradley44 Bigliani et al.46 Hawkins and Janda45 Gerber and colleagues48 Misamore and Facibene49 Arciero and colleagues50 Total/mean
No. of Follow-up Recurrence Year Patients (mo) Rate 1989 1993 1995 1996 2000 2000
11 40 34 14 24 14
60 24-120 60 44 91 45
17% 40% 12% 0% 23% 7%
2005
12 149
40 59
8% 15%
rotation), circumduction test, jerk test, and Kim test all help to clearly delineate the pathology of posterior instability and have shown good reliability in the literature.41-43 The ability to address capsular redundancy, in addition to the labrum and rotator interval, increases the likelihood of a successful outcome in patients who are amenable to arthroscopic treatment.32 Historically, open posterior shoulder stabilization (in patients without osseous defects) has been fraught with unacceptably high recurrence rates in an active patient population. Arthroscopic treatment in this patient population is very promising, with results rivaling or surpassing those of anterior instability in very high-demand patients. Averaging the results of multiple studies in the literature gives an overall recurrence rate for open posterior capsular shift of 15%, with a range of 0% to 40% (Table 3).44-50 Although Hawkins and Janda45 showed a very low recurrence rate in their series, only 29% of patients were able to return to sports and only 1 contact athlete was included in the study. In a recent study by Rhee et al.,51 92.6% of patients undergoing an open posterior shift had a successful outcome; however, the recurrence rate was 13.3% when patients with voluntary subluxation were included in the final analysis. These results are comparable to those observed by Wolf et al.,52 with a recurrence rate of 19%. In patients who wish to return to collision sports or overhead throwing, these recurrence rates would be unacceptably high, and more modern arthroscopic approaches have significantly improved outcomes. There are multiple advantages of arthroscopic stabilization for recurrent posterior instability. As with anterior instability, the surgeon has the ability to address capsular laxity and tearing in addition to concomitant pathology, such as SLAP lesions, anterior labral tears, rotator interval lesions, and rota-
1427
tor cuff tears. In addition to posterior instability, the surgeon can also address multidirectional instability (MDI) with an “around-the-world” capsular plication when necessary, because these pathologies can commonly coexist. There is also less morbidity with an arthroscopic approach, and the results show superior outcomes, even in high-demand athletic patients. When reviewing studies evaluating modern arthroscopic techniques for the treatment of posterior shoulder instability (excluding studies that incorporated thermal capsulorrhaphy), we found recurrence rates ranging from 0% to 10%, with a mean of 5.3% (Table 4).53-57 In a direct comparison study of open versus arthroscopic posterior capsulorrhaphy, Arciero and colleagues50 found that functional outcomes were significantly improved in the patients who underwent arthroscopic fixation. In a review of 16 studies, Schepsis and colleagues58 compared arthroscopic and open techniques with regard to recurrence rates and return to sports and found no significant differences between groups; however, patients in the arthroscopic group reported higher satisfaction, and the arthroscopic studies analyzed did not include modern methods as reported in this review (no studies after 2004). Perhaps the greatest endorsement of arthroscopic posterior labral repair can be found from reviewing the data with regard to contact and throwing athletes, a subset of patients placing very high demands on the shoulder. In the study of Kim et al.,54 12 patients were contact athletes and 92% remained stable at final follow-up. Mair et al.59 evaluated 9 contact athletes after arthroscopic tack fixation of the posterior labrum and reported a 100% success rate at 2-year follow-up. In a study by one of us (J.P.B.), 51 contact athletes were included in the analysis of patients who underwent arthroscopic treatment for unidirectional posterior instability.55 Of these patients, 34 were football players (19 professional, 5 collegiate, and 10 high school), 7 TABLE 4.
Results of Arthroscopic Posterior Stabilization
Author Williams et al.53 Kim et al.54 Arciero and colleagues50 Bradley et al.55 Savoie et al.56 Snyder and colleagues57 Total/mean
No. of Follow-up Recurrence Year Patients (mo) Rate 2003 2003 2005 2006 2009 2010
26 27 19 91 131 29 323
61 39 40 48 28 66 47
7% 4% 10% 5% 3% 3% 5%
1428
F. P. TJOUMAKARIS AND J. P. BRADLEY MULTIDIRECTIONAL INSTABILITY
FIGURE 7. Arthroscopic view of a left shoulder from the posterior portal (lateral decubitus position) showing a “drive-through” sign with laxity of the anterior and inferior capsule. The humeral head and glenoid are barely visible in the same image in this patient with MDI.
were wrestlers, 6 played basketball, 2 played lacrosse, 1 played rugby, and 1 participated in martial arts. At 28 months’ follow-up, 94% of patients had good/excellent results by American Shoulder and Elbow Surgeons criteria and in 5 patients the procedure had failed (9.8%). Of the 5 patients in whom the stabilization procedure had failed, 4 underwent a capsular plication without suture anchors, implicating loss of fixation as a possible cause. In another study by the senior author (J.P.B.), 27 throwers underwent posterior instability repair at a mean follow-up of 27 months.60 At final follow-up, 89% of patients achieved good/excellent results based on the American Shoulder and Elbow Surgeons functional score, with 3 patients reporting failure during this time period. All 3 patients with failure were noted to have undergone posterior capsular plication without suture anchors, again raising the suspicion of loss of fixation as an etiologic factor. In an analysis of patients with type VIII SLAP lesions, which are commonly found in contact and throwing athletes, 100% of patients were able to return to sports after posterior and superior labral repair, with 69% of patients returning at their preinjury level.61 These most recent data show the superiority of arthroscopic treatment compared with historical open techniques in the absence of well-designed randomized trials (Video 1, available at www.arthroscopyjournal.org).
MDI has been a vexing problem for shoulder surgeons over the past several decades. Patients present with instability of the shoulder in several planes of motion and often have signs consistent with generalized ligamentous laxity. Although rehabilitation with rotator cuff and scapular muscle strengthening is the current gold standard of treatment after initial diagnosis, this regimen will fail in a significant number of patients.62 Treatment with open inferior capsular shift has been met with success in patients in whom a comprehensive physical therapy program fails.63 The validity of arthroscopic capsular shift was questioned in a recent study when it was found that an open capsular shift reduced shoulder volume better than an arthroscopic plication.64 The authors of that study found that open shift reduced capsular volume by 50% whereas arthroscopic methods were accompanied by a reduction of 22.8%. In a more recent study by Sekiya et al.,65 a multi-pleated arthroscopic capsular plication using suture anchors was found to be more effective in reducing capsular volume than traditional open means (58% reduction v 45% reduction) (Figs 7 and 8). Studies evaluating the success of arthroscopic capsular plication have shown excellent results in the current orthopaedic literature that rival the success of traditional open techniques.66-68 In a study evaluating the success of a modern suture anchor arthroscopic technique in high-demand athletes, the senior author (J.P.B.) found that 91% of the patients had full or
FIGURE 8. Arthroscopic view of a right shoulder from the anterior portal (lateral decubitus position) showing a multi-pleated plication of the posterior capsule in a patient with MDI.
ARTHROSCOPIC SHOULDER STABILIZATION
FIGURE 9. Coronal T2 magnetic resonance imaging sequence of a right shoulder showing humeral avulsion of the inferior glenohumeral ligament in a patient with recurrent anterior instability of the shoulder.
satisfactory range of motion and 86% of the athletes were able to return to their previous level of sport.69 Despite the comparable success rates of arthroscopic and open capsular shift in patients with MDI, we currently advocate an all-arthroscopic approach. A significant number of patients with MDI will also have findings consistent with posterior instability (Kim lesions, posterior labral tears, and so on), and an open anterior approach makes addressing this concomitant pathology challenging. In addition, because MDI is not routinely associated with bony deficiency, the ability to perform an anterior and posterior pan-capsular plication arthroscopically addresses the full spectrum of instability in this patient population. With suture anchors supplanting suture-only repair as the more preferred method in recent studies, patients who place high demands on their shoulders are ever increasing their ability to return to high-level activities and sports. OTHER CONSIDERATIONS (HAGL, CONTACT ATHLETES) As our understanding of the complex nature of shoulder instability has evolved, so has our ability to treat the spectrum of disease. With high-resolution magnetic resonance imaging and arthrogram evaluation, avulsion of the glenohumeral ligaments from the
1429
humerus is increasingly recognized as a significant source of morbidity.7 Currently, HAGL lesions are considered among the most difficult lesions to address arthroscopically (Fig 9). Although we still use an open approach as our preferred method of treatment for adequate visualization, we recognize the success of several authors in the ability to repair these lesions arthroscopically.70-72 Typically, a 70° arthroscope is used to visualize the insertion of the inferior glenohumeral ligaments on the humerus, and an inferior accessory portal is used to ensure anatomic placement of the suture anchor within the insertion site. As mentioned previously, contact and collision athletes are a patient population that is predisposed to a high recurrence rate after stabilization based on the high demands placed on the shoulder during these activities. The high-energy nature of subluxation and dislocation events in football, rugby, and hockey can result in significant bony and soft-tissue damage. Because of this, contact athletes are prone to higher dislocation rates after anterior stabilization procedures.73,74 We believe that contact athletes with capsular laxity and disruption of the capsulolabral complex without bony lesions can be treated successfully with modern arthroscopic methods. In a study by Mazzocca et al.,75 100% of contact athletes treated with arthroscopic stabilization were able to return to organized high school or collegiate sports. This study supports the thesis that adherence to modern principles of reducing capsular laxity, using suture anchors, and addressing concomitant pathology (rotator interval laxity) can result in favorable outcomes in cases that were traditionally treated with an open technique. DISCUSSION The majority of patients who present with shoulder instabilities can be treated by an all-arthroscopic apTABLE 5.
Contraindications to Arthroscopic Shoulder Repair
Patient-Related Factors Medically unstable patient Uncontrolled seizure disorder Collagen disorders (Marfan syndrome, Ehlers-Danlos syndrome) Secondary gain or voluntary subluxation
Surgical Factors/Decision Making Engaging Hill-Sachs defects (ⱖ30% of humeral head) Significant glenoid bone defects (ⱖ25%) Capsular deficiency (prior thermal capsulorrhaphy) Presence of HAGL lesions (relative contraindication)
1430
F. P. TJOUMAKARIS AND J. P. BRADLEY
TABLE 6.
Pearls and Pitfalls of Arthroscopic Shoulder Stabilization
Pearls (Figs 10–12) Preoperative computed tomography scan may help clearly define size of bone defects.
The lateral decubitus position may offer easier access to the posterior labrum.
Plication of the inferior capsule and the use of 3 or more anchors help to lessen the rate of recurrence in anterior instability.
Pitfalls Placing the anchors on the glenoid neck (rather than the face) may not adequately restore the length/tension relation of the glenohumeral ligaments. Failure to recognize and treat concomitant laxity of the posterior/anterior/superior capsule may increase the likelihood of recurrence (of both instability and symptoms). For Bankart repair, the first anchor is traditionally placed low on the glenoid face (below the 5-o’clock position).
proach. Whereas a subset of patients may require open treatment because of osseous defects and deformities about the shoulder, the absolute contraindications to arthroscopic stabilization are dwindling (Table 5). Arthroscopic treatment offers the advantage of a minimally invasive approach with less soft-tissue scarring, restriction in motion, and subscapularis failure. In addition, the ability to simultaneously address con-
FIGURE 10. Arthroscopic view from the posterior portal of a right shoulder (lateral decubitus position) showing elevation of the torn labrum/capsule from the glenoid neck.
FIGURE 11. Arthroscopic view from the posterior portal of a left shoulder (lateral decubitus position) showing placement of the first anchor low on the face of the glenoid (below the 5-o’clock position).
comitant pathology such as SLAP lesions, rotator interval lesions, and posterior and inferior capsular laxity places the arthroscope at the top of our treatment pyramid. Current studies comparing an evolved arthroscopic technique with traditional open means show equivalent or better outcomes, particularly in
FIGURE 12. Arthroscopic view from the anterior portal of a right shoulder (lateral decubitus position) showing restoration of the capsulolabral complex to the anterior glenoid rim.
ARTHROSCOPIC SHOULDER STABILIZATION athletes. With recent advances in musculoskeletal imaging, preoperative planning has become paramount in understanding the complex and multifactorial nature of shoulder instability. Patients are rarely believed to have unidirectional instability today, and recognition of the full spectrum of instability, which can include elements of MDI, has become more prevalent among shoulder-trained surgeons (Table 6). With these advancements in diagnosis comes a better understanding of arthroscopic means of fixation. With modern techniques that use multiple suture anchors aimed at reducing capsular and ligamentous laxity, we are able to achieve stability that was previously believed to only occur after open stabilization. This is perhaps most beneficial to our athletic patients who are determined to return to their previous level of play without morbidity or restriction in shoulder range of motion (Figs 10 –12). Current arthroscopic techniques have evolved to where arthroscopy should be the preferred method of repair for anterior instability, posterior instability, and MDI, because the results show equal stability, better motion, improved functional outcomes, and most importantly, return to sports.
11.
12.
13. 14. 15.
16. 17.
18.
19.
REFERENCES 20. 1. Green MR, Christensen KP. Arthroscopic versus open Bankart procedures: A comparison of early morbidity and complications. Arthroscopy 1993;9:371-374. 2. Sisto DJ, Cook DL. Intraoperative decision making in the treatment of shoulder instability. Arthroscopy 1998;14:389394. 3. Stein DA, Jazrawi L, Bartolozzi AR. Arthroscopic stabilization of anterior shoulder instability: A review of the literature. Arthroscopy 2002;18:912-924. 4. Hobby J, Griffin D, Dunbar M, Boileau P. Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations. J Bone Joint Surg Br 2007;89:1188-1196. 5. Owens CB, Nelson BJ, Duffey ML, et al. Pathoanatomy of first-time, traumatic, anterior glenohumeral subluxation events. J Bone Joint Surg Am 2010;92:1605-1611. 6. Rothberg DL, Burks RT. Capsular tear in line with the inferior glenohumeral ligament: A cause of anterior glenohumeral instability in 2 patients. Arthroscopy 2009;25:934-936. 7. Wolf EM, Cheng JC, Dickson JC. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607. 8. Antonio GE, Griffith JF, Yu AB, Yung PS, Chan KM, Ahuja AT. First-time shoulder dislocation: High prevalence of labral injury and age-related differences revealed by MR arthrography. J Magn Reson Imaging 2007;26:983-991. 9. Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am 1984;66:159-168. 10. Sekiya JK, Wickwire AC, Stehle JH, Debski RE. Hill-Sachs defects and repair using osteoarticular allograft transplanta-
21.
22.
23. 24. 25. 26.
27. 28. 29.
1431
tion: Biomechanical analysis using a joint compression model. Am J Sports Med 2009;37:2459-2466. 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: 677-694. Itoi E, Lee SB, Amrami KK, Wenger DE, An KN. Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography. Am J Sports Med 2003;31:112-118. Lafosse L, Boyle S. Arthroscopic Latarjet procedure. J Shoulder Elbow Surg 2010;19:2-12. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy 2008;24:723-726. Skendzel JG, Sekiya JK. Arthroscopic glenoid osteochondral allograft reconstruction without subscapularis takedown: Technique and literature review. Arthroscopy 2011;27:129135. Boileau P, Richou J, Lisai A, Chuinard C, Bicknell RT. The role of arthroscopy in revision of failed open anterior stabilization of the shoulder. Arthroscopy 2009;25:1075-1084. Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V. Arthroscopic salvage of failed arthroscopic Bankart repair: A prospective study with a minimum follow-up of 4 years. Am J Sports Med 2008;36:1330-1336. 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. 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. Freedman KB, Smith AP, Romeo AA, Cole BJ, Bach BR. 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. Mohtadi NG, Bitar IJ, Sasyniuk TM, Hollinshead RM, Harper WP. Arthroscopic versus open repair for traumatic anterior shoulder instability: A meta-analysis. Arthroscopy 2005;21: 652-658. Boileau P, Villalba M, Héry 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: 1755-1763. Kim SH, Ha KI, Kim SH. Bankart repair in traumatic anterior shoulder instability: Open versus arthroscopic technique. Arthroscopy 2002;18:755-763. Kim SH, Ha KI, Cho YB, Ryu BD, Oh I. Arthroscopic anterior stabilization of the shoulder: Two- to six-year follow-up. J Bone Joint Surg Am 2003;85:1511-1518. Tjoumakaris FP, Abboud JA, Hasan SA, Ramsey ML, Williams GR. Arthroscopic and open Bankart repairs provide similar outcomes. Clin Orthop Relat Res 2006;446:227-232. 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. Pulavarti RS, Symes TH, Rangan A. Surgical interventions for anterior shoulder instability in adults. Cochrane Database Syst Rev 2009;4:CD005077. Petrera M, Patella V, Patella S, et al. A meta-analysis of open versus arthroscopic Bankart repair using suture anchors. Knee Surg Sports Traumatol Arthrsoc 2010;18:1742-1747. Sachs RA, Williams B, Stone ML, Paxton L, Kuney M. Open
1432
30. 31. 32. 33. 34.
35. 36.
37. 38.
39.
40.
41. 42. 43. 44. 45. 46.
47. 48. 49.
50.
F. P. TJOUMAKARIS AND J. P. BRADLEY
Bankart repair: Correlation of results with postoperative subscapularis function. Am J Sports Med 2005;33:1458-1462. Wang C, Ghalambor N, Zarins B, Warner JJ. Arthroscopic versus open Bankart repair: Analysis of patient subjective outcome and cost. Arthroscopy 2005;21:1219-1222. Barber FA, Click SD, Weideman CA. Arthroscopic or open Bankart procedures: What are the costs? Arthroscopy 1998; 14:671-674. Robinson CM, Aderinto J. Recurrent posterior shoulder instability. J Bone Joint Surg Am 2005;87:883-892. Arciero RA, Mazzocca AD. Traumatic posterior shoulder subluxation with labral injury: Suture anchor technique. Tech Shoulder Elbow Surg 2004;5:13-24. Wirth MA, Seltzer DG, Rockwood CA Jr. Recurrent posterior glenohumeral dislocation associated with increased retroversion of the glenoid. A case report. Clin Orthop Relat Res 1994:98-101. Modi CS, Wicks L, Srinivasan K. Reconstruction of humeral head defect for locked posterior shoulder dislocation. Orthopedics 2009;32:691. Gerber C, Lambert SM. 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 1996;78:376-382. Harryman DT II, Sidles JA, Harris SL, Matsen FA. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66. Kim SH, Noh KC, Park JS, Ryu BD, Oh I. Loss of chondrolabral containment of the glenohumeral joint in atraumatic posteroinferior multidirectional instability. J Bone Joint Surg Am 2005;87:92-98. Kim SH, Ha KI, Yoo JC, Noh KC. Kim’s lesion: An incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthroscopy 2004;20:712-720. Safran O, Defranco MJ, Hatem S, Iannotti JP. Posterior humeral avulsion of the glenohumeral ligament as a cause of posterior shoulder instability. A case report. J Bone Joint Surg Am 2004;86:2732-2736. Kim SH, Park JC, Park JS, Oh I. Painful jerk test: A predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. Am J Sports Med 2004;32:1849-1855. Kim SH, Park JS, Jeong WK, Shin SK. The Kim test: A novel test for posteroinferior labral lesion of the shoulder—A comparison to the jerk test. Am J Sports Med 2005;33:1188-1192. Tzannes A, Paxinos A, Callanan M, Murrell GA. An assessment of the interexaminer reliability of tests for shoulder instability. J Shoulder Elbow Surg 2004;13:18-23. Tibone JE, Bradley JP. The treatment of posterior subluxation in athletes. Clin Orthop Relat Res 1993:124137. Hawkins RJ, Janda DH. Posterior instability of the glenohumeral joint. A technique of repair. Am J Sports Med 1996;24: 275-278. Bigliani LU, Pollock RG, McIlveen SJ, Endrizzi DP, Flatow EL. Shift of the posteroinferior aspect of the capsule for recurrent posterior glenohumeral instability. J Bone Joint Surg Am 1995;77:1011-1020. Fronek J, Warren RF, Bowen M. Posterior subluxation of the glenohumeral joint. J Bone Joint Surg Am 1989;71:205-216. Fuchs B, Jost B, Gerber C. Posterior-inferior capsular shift for the treatment of recurrent, voluntary posterior subluxation of the shoulder. J Bone Joint Surg Am 2000;82:16-25. Misamore GW, Facibene WA. Posterior capsulorrhaphy for the treatment of traumatic recurrent posterior subluxations of the shoulder in athletes. J Shoulder Elbow Surg 2000;9:403408. Bottoni CR, Franks BR, Moore JH, DeBerardino TM, Taylor DC, Arciero RA. Operative stabilization of posterior shoulder instability. Am J Sports Med 2005;33:996-1002.
51. Rhee YG, Lee DH, Lim CT. Posterior capsulolabral reconstruction in posterior shoulder instability: Deltoid saving. J Shoulder Elbow Surg 2005;14:355-360. 52. Wolf BR, Strickland S, Williams RJ, Allen AA, Altchek DW, Warren RF. Open posterior stabilization for recurrent posterior glenohumeral instability. J Shoulder Elbow Surg 2005;14: 157-164. 53. Williams RJ III, Strickland S, Cohen M, Altchek DW, Warren RF. Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209. 54. Kim SH, Ha KI, Park JH, et al. Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder. J Bone Joint Surg Am 2003;85:1479-1487. 55. Bradley JP, Baker CL III, Kline AJ, Armfield DR, Chhabra A. Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: A prospective study of 100 shoulders. Am J Sports Med 2006;34:1061-1071. 56. Savoie FH III, Holt MS, Field LD, et al. Arthroscopic management of posterior instability: Evolution of technique and results. Arthroscopy 2009;24:389-396. 57. Bahk MS, Karzel RP, Snyder SJ. Arthroscopic posterior stabilization and anterior capsular plication for recurrent posterior glenohumeral instability. Arthroscopy 2010;26:1172-1180. 58. Kakar S, Voloshin I, Kaye EK, et al. Posterior shoulder instability: Comprehensive analysis of open and arthroscopic approaches. Am J Orthop 2007;36:655-659. 59. Mair SD, Zarzour RH, Speer KP. Posterior labral injury in contact athletes. Am J Sports Med 1998;26:753-758. 60. Radkowski CA, Chhabra A, Baker CL III, Tejwani SG, Bradley JP. Arthroscopic capsulolabral repair for posterior shoulder instability in throwing athletes compared with nonthrowing athletes. Am J Sports Med 2008;36:693-699. 61. Seroyer S, Tejwani SG, Bradley JP. Arthroscopic capsulolabral reconstruction of the type VIII superior labrum anterior posterior lesion: Mean 2-year follow-up on 13 shoulders. Am J Sports Med 2007;35:1477-1483. 62. Misamore GW, Sallay PI, Didelot W. A longitudinal study of patients with multidirectional instability of the shoulder with seven- to ten-year follow-up. J Shoulder Elbow Surg 2005;14: 466-470. 63. Neer CS II, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am 1980;62:897-908. 64. Cohen SB, Wiley W, Goradia VK, Pearson S, Miller MD. Anterior capsulorrhaphy: An in vitro comparison of volume reduction—Arthroscopic plication versus open capsular shift. Arthroscopy 2005;21:659-664. 65. Sekiya JK, Willobee JA, Miller MD, Hickman AJ, Willobee A. Arthroscopic multi-pleated capsular plication compared with open inferior capsular shift for reduction of shoulder volume in a cadaveric model. Arthroscopy 2007;23:11451151. 66. 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. 67. Treacy SH, Savoie FH III, Field LD. Arthroscopic treatment of multidirectional instability. J Shoulder Elbow Surg 1999;8: 345-350. 68. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of bidirectional glenohumeral instability: Two- to five-year follow-up. J Shoulder Elbow Surg 2001;10:28-36. 69. Baker CL III, Mascarenhas R, Kline AJ, Chhabra A, Pombo MW, Bradley JP. Arthroscopic treatment of multidirectional shoulder instability in athletes: A retrospective analysis of 2to 5-year clinical outcomes. Am J Sports Med 2009;37:17121720.
ARTHROSCOPIC SHOULDER STABILIZATION 70. Kon Y, Shiozaki H, Sugaya H. Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy 2005;21:632.e1-632.e6. 71. Richards DP, Burkhart SS. Arthroscopic humeral avulsion of the glenohumeral ligaments (HAGL) repair. Arthroscopy 2004;20:134-141. 72. Chhabra A, Diduch DR, Anderson M. Arthroscopic repair of a posterior humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion. Arthroscopy 2004;20:73-76 (Suppl). 73. Uhorchak JM, Arciero RA, Huggard D, Taylor DC. Recurrent
1433
shoulder instability after open reconstruction in athletes involved in collision and contact sports. Am J Sports Med 2000;28:794-799. 74. Pagnani MJ, Dome DC. Surgical treatment of traumatic anterior shoulder instability in American football players. J Bone Joint Surg Am 2002;82:711-715. 75. Mazzocca AD, Brown FM, Carreira DS, Hayden J, Romeo AA. Arthroscopic anterior shoulder stabilization of collision and contact athletes. Am J Sports Med 2005;33: 52-60.
The Rationale for an Arthroscopic Approach to Shoulder Stabilization Fotios P. Tjoumakaris, M.D., and James P. Bradley, M.D.
Abstract: The gold standard of treatment for glenohumeral instability has traditionally been viewed as open shoulder stabilization. With the increased awareness of complex instability patterns and the ability to preoperatively detect concomitant pathology with advanced imaging modalities, an evidence-based shift to an all-arthroscopic approach to shoulder stabilization surgery is occurring. Current data suggest that patients who meet eligibility criteria for arthroscopic stabilization (those without significant bony lesions or significant deformity) can expect equivalent rates of recurrence, better functional outcomes, and less morbidity. Modern arthroscopic techniques using suture anchors and capsular plication have resulted in a significant improvement over previous reports in the orthopaedic literature. An argument is put forth on the benefits of an all-arthroscopic approach to shoulder stabilization in athletes and nonathletes alike based on a review of the current orthopaedic literature comparing the evolved arthroscopic technique with more traditional open methods.
A
rthroscopic shoulder stabilization for recurrent glenohumeral instability has evolved considerably over the past 2 decades. Advantages of an allarthroscopic technique are numerous, ranging from preservation of the subscapularis to the ability to address a multitude of concomitant pathologies. In addition, arthroscopic stabilization can potentially provide more favorable range of motion and early return
From the Department of Orthopaedic Surgery, Rothman Institute Orthopaedics, Thomas Jefferson University (F.P.T.), Philadelphia; Department of Orthopaedic Surgery, University of Pittsburgh Medical Center (J.P.B.), Pittsburgh; Pittsburgh Steelers (J.P.B.), Pittsburgh; and Burke and Bradley Orthopaedics (J.P.B.), Pittsburgh, Pennsylvania, U.S.A. J.P.B. receives royalties and research grants from Arthrex. The authors report no conflict of interest. Received November 12, 2010; accepted June 3, 2011. Address correspondence to James P. Bradley, M.D., Burke and Bradley Orthopaedics, 200 Delafield Rd, Ste 4010, Pittsburgh, PA 15215, U.S.A. E-mail: [email protected] © 2011 by the Arthroscopy Association of North America 0749-8063/10683/$36.00 doi:10.1016/j.arthro.2011.06.006 Note: To access the video accompanying this report, visit the October issue of Arthroscopy at www.arthroscopyjournal.org.
1422
to full functional activity in high-demand patients.1 Despite these advantages, widespread acceptance of an all-arthroscopic approach to shoulder instability among members of the orthopaedic community is lacking, partly because of the high failure rate that was reported in early studies on recurrent anterior instability.2-4 Modern suture anchor devices combined with a trend away from transglenoid sutures and metallic staples have been responsible for a great deal of success in more recent studies. In addition to these technical advancements, our understanding of the multifactorial etiology of glenohumeral instability and our ability to recognize complex injury patterns with advanced imaging modalities have led to a tailored approach to the patient with recurrent shoulder instability. Shoulder instability can range in severity from a subluxation event to a dislocation of the glenohumeral articulation. The direction of instability can be classified as anterior, posterior, or multidirectional, and patients may have recurrence of symptoms after significant trauma (i.e., collision) or relatively atraumatic events (i.e., activities of daily living). Very minimal symptoms and physical signs can often be accompanied by significant findings with magnetic resonance
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 27, No 10 (October), 2011: pp 1422-1433
ARTHROSCOPIC SHOULDER STABILIZATION imaging and arthroscopic visualization even in the absence of frank dislocation.5 Historical classification systems attempt to simplify the injury pattern into traumatic versus atraumatic, direction (anterior/posterior), and chronicity; however, patients may present anywhere along this spectrum and may require a more complex surgical management algorithm when operative intervention is indicated. In the following discussion we will review the use of modern arthroscopic techniques for the treatment of simple and complex instability patterns of the shoulder. The justification for evolving from an open surgical technique to an all-arthroscopic approach for shoulder stabilization will be analyzed from a review of current literature and a comparison of similar techniques. Through this analysis, it is our hope to clearly define the indications and make a case for an allarthroscopic approach; in addition, we will delineate the contraindications when appropriate.
1423
FIGURE 2. Axial T2 magnetic resonance imaging scan of a right shoulder showing a Hill-Sachs lesion (asterisk) of the posterolateral humeral head.
ANTERIOR INSTABILITY Traditionally, anterior instability was thought of as a fairly simple injury pattern resulting in a dislocation of the humeral head off of the anterior glenoid rim. With advanced imaging modalities and detailed arthroscopic visualization, pathology has been recognized beyond the presence of Bankart and Hill-Sachs lesions (Figs 1 and 2). Patients with anterior instability may present with significant capsular injury ranging
from elongation and plastic deformation of the anterior capsule to capsular tearing that contributes to the instability pattern (Fig 3).6 Humeral avulsion of the glenohumeral ligament (HAGL) lesions are rare occurrences but, when present, are a significant source of morbidity.7 Rotator interval lesions (coracohumeral ligament, superior glenohumeral ligament) and SLAP tears can also be found concomitantly with other labral and ligamentous pathology and complicate this
FIGURE 1. Axial T2 magnetic resonance imaging scan of a right shoulder showing a Bankart lesion or avulsion of the inferior capsulolabral complex from the glenoid rim.
FIGURE 3. Arthroscopic view of a right shoulder from the posterior portal (lateral decubitus position) showing an anterior capsular tear in a patient with multiple failed stabilization procedures.
1424
F. P. TJOUMAKARIS AND J. P. BRADLEY
FIGURE 4. Arthroscopic view of a left shoulder from the posterior portal (lateral decubitus position) showing a Hill-Sachs lesion that engaged in late abduction/external rotation (asterisks).
instability pattern.8 Historical treatment of anterior instability has included nonoperative management such as slings and orthotics, as well as therapeutic exercises and lifestyle modification. When surgical intervention is warranted, open or arthroscopic stabilization can be considered; however, historically, open stabilization has been superior to arthroscopic treatment in this patient cohort. There are clear indications for open treatment of anterior instability. Patients with large Hill-Sachs lesions that “engage” in early abduction and external rotation have been shown to have higher recurrence rates after isolated capsulolabral reconstruction.9 The issue of whether a Hill-Sachs lesion is deemed “significant” is controversial, and some authors have reported that lesions as small as 12.5% of the humeral head diameter may cause significant biomechanical alterations.10 For our purposes, we define significant Hill-Sachs lesions as those that are likely to engage the glenoid rim in a position of function when the arm is in abduction and external rotation, as described by Burkhart and De Beer11 (Fig 4). Glenoid bone deficiency, as is the case with humeral head defects, can also significantly increase the recurrence rate after isolated capsular and labral repair. Rowe et al.9 have stated that glenoid bone defects comprising more than 30% of the glenoid were a contraindication to repair alone, and Itoi et al.12 showed that defects comprising 21% of the total glenoid length had recurrent instability and decreased motion. Arthroscopic means to address bone deficiencies of the shoulder have been
reported, and the results are encouraging13,14; however, further studies are needed to validate these techniques and their long-term effectiveness. Recently, Skendzel and Sekiya15 described a novel technique of osteoarticular arthroscopic glenoid reconstruction without violating the subscapularis. Although longterm results of all of these techniques are currently lacking, they have shown promise in addressing bone deficiency through a minimally invasive approach. Soft-tissue deficiencies, in addition to osseous deficiencies, may also necessitate an open approach, as can sometimes be seen in capsular deficiency after multiple stabilizations or when the subscapularis is torn. Revision surgery in and of itself should not be viewed as an absolute contraindication to an arthroscopic approach. Studies have shown success in restoring stability after previously failed open and arthroscopic stabilizations with more modern arthroscopic techniques.16,17 In the absence of clear contraindications, we believe that arthroscopic stabilization for anterior instability can achieve comparable results to open stabilization with modern arthroscopic techniques. Studies comparing the outcomes of open and arthroscopic techniques are numerous but warrant further analysis to determine whether the benefits of open surgery outweigh the potential complications and to determine whether they can be extrapolated to modern techniques. In a study by Hubbell et al.,18 failure occurred at a significantly higher rate in patients undergoing arthroscopic fixation compared with the open cohort (nearly 60% of patients in the arthroscopic group had symptoms of instability); however, improved stability in the open group came at a significant cost to range of motion (18° deficit in external rotation). This study used transglenoid suture fixation, which is no longer used for arthroscopic stabilization. Karlsson et al.19 performed a similar study using biodegradable tacks and found similar functional outcomes between patient cohorts; however, the failure rate was higher in the arthroscopic group (15% v 10%). These authors again found that open stabilization was associated with more significant range of motion loss (10°) (Table 1). In a meta-analysis evaluating 6 studies, Freedman et al.20 found that superior results with regard to recurrent instability (3% v 13%), total recurrence (10% v 20%), and outcome (good/excellent in 88% v 71%) were demonstrated when open surgery was compared with an arthroscopic technique. In another metaanalysis, with the inclusion of 11 studies, the only similarity observed between these 2 methods was the reoperation rate, with open stabilization showing su-
ARTHROSCOPIC SHOULDER STABILIZATION TABLE 1.
Results of “Traditional” Arthroscopic Anterior Shoulder Stabilization
Author
Year
Karlsson et al.19 Hubbell et al.18 Freedman et al.20 Total/mean
2001 2004 2004
No. of Patients
Follow-up (mo)
66 20 172 258
28 60 24* 37
Recurrence Rate 15% 17% 13% 15%
*Minimum length of follow-up for study inclusion.
periority with regard to instability and return to activity.21 Examination of these studies further, however, shows that the literature is comparing a technique that has withstood the test of time with an arthroscopic approach that was still early in its evolution and is now essentially outdated. The first meta-analysis analyzed patients who underwent transglenoid suture and tack fixation, which has fallen out of favor over the past several years. In the more recent analysis, of the initial 18 studies that were eligible for review, only 2 reported on a modern arthroscopic technique. Previous studies have fallen victim to analyzing heterogeneous patient populations with a wide array of pathologies using varied techniques with no clear definitions of success and failure. More recent studies paint a clearer picture of where an arthroscopic approach has come thus far. What precisely defines a “modern” arthroscopic technique can vary from surgeon to surgeon; however, as we attempt to standardize our approach to treatment, several principles have evolved and influenced outcomes. Three principles currently define our approach to treatment: the use of multiple suture anchors (ⱖ3), a proximal shift of the anterior capsule and capsular plication to address capsular laxity, and treatment of associated intra-articular pathologies (rotator interval lesions, SLAP tears, capsular rents). In a study by Boileau et al.,22 patients with significant inferior instability, those with anterior capsular laxity, and those in whom fewer than 4 anchor points were used were at significant risk for recurrence with a suture anchor arthroscopic approach. Studies that take these principles into account when comparing techniques offer us additional insight into our current approach for anterior instability. In the first study to evaluate a modern technique and an open procedure, Kim et al.23 found equal rates of recurrence in both groups (10%); however, the arthroscopic group had better functional outcomes at 3-year follow-up. In a follow-up to this study analyzing 167 patients, Kim et
1425
al.24 found a 4% recurrence rate with good to excellent results in 95% of patients at 2 to 6 years, with over 90% of patients returning to their previous level of sport. The mean loss of external rotation was only 2°, and recurrence was associated with glenoid deficiency in excess of 30%, in agreement with the previous report by Rowe et al.9 In a previous study, 1 of us (F.P.T.) reported on a modern arthroscopic technique using suture anchors and an open technique using identical implants.25 Patient-assessed outcomes were similar in both groups, and there was no difference in recurrence at 2-year follow-up. In a randomized controlled study, Fabbriciani et al.26 assessed outcomes in a series of patients assigned to either an arthroscopic or open approach. Sixty patients were studied and analyzed at 2-year follow-up, with no difference in recurrence rates between groups and better overall range of motion in the arthroscopic group. In a Cochrane Database systematic review evaluating randomized trials of open and arthroscopic Bankart repairs for anterior shoulder instability, the authors found no difference between the groups and could make no formal recommendations for one approach over the other.27 Critical comparisons in this study were made for recurrence of instability, reoperation on the affected shoulder, or surgery for any reason. Shoulder outcomes were also found to be similar between groups when using these rigorous study criteria. In agreement with these findings were the results of a more recent meta-analysis analyzing more modern suture anchor techniques in open and arthroscopic surgery.28 The authors found that studies done after 2002 showed significant differences in recurrence rates in favor of arthroscopy (2.9% v 9.2%). Analysis of all the data showed recurrence rates to be similar between groups (6% for arthroscopic approach v 6.7% for open approach) (Table 2). On the basis of these recent data, it is reasonable to TABLE 2.
Results of “Modern” Arthroscopic Anterior Shoulder Stabilization
Author
Year
Kim et al.23 Tjoumakaris et al.25 Fabbriciani et al.26 Pulavarti et al.27 Petrera et al.28 Total/mean
2002 2006 2004 2009 2010
No. of Patients
Follow-up (mo)
58 69 30 92 234 483
39 24* 24 24* 24* 27
*Minimum length of follow-up for study inclusion.
Recurrence Rate 10% 1% 0% 8% 6% 5%
1426
F. P. TJOUMAKARIS AND J. P. BRADLEY
FIGURE 5. Axial T2 magnetic resonance imaging scan of a right shoulder showing a posterior labral tear (asterisk).
make the assertion that the gap with regard to the recurrence of instability has closed after arthroscopic capsulolabral repair for anterior instability. Advantages of an arthroscopic repair in this patient cohort include less perioperative morbidity; fewer postoperative motion problems, obviating the need for subscapularis healing; improved strength of the subscapularis; ability to address concomitant pathology; and less postoperative pain and need for hospital admission.29-31 Range-of-motion loss in external rotation of up to 20°, as has been reported in some studies of open Bankart repair, would be particularly challenging and unacceptable for any high-demand athlete wishing to return to competitive play. As such, our current approach for recurrent anterior glenohumeral instability in all patients regardless of sport, and in the absence of the aforementioned contraindications, is to use an all-arthroscopic technique.
so on). In the past, posterior shoulder instability has presented both a diagnostic and therapeutic challenge for shoulder surgeons; however, with advanced imaging techniques and modern arthroscopic repair methods, the successful recognition and treatment of patients with this pathology are now commonplace (Figs 5 and 6). As with anterior instability, significant bone defects (reverse Hill-Sachs lesions), glenoid deficiency or retroversion, and capsular deficiencies (reverse HAGL lesions) may still warrant an open approach to treatment when they contribute to this instability pattern and have been described in the literature.34-36 A number of theories and a variety of pathologies have been reported to be the contributing cause in patients with posterior shoulder instability. Glenoid retroversion or hypoplasia, relative chondrolabral retroversion, humeral retroversion, reverse Hill-Sachs lesions, reverse Bankart lesions, rotator interval lesions, capsular attenuation and laxity, and Kim lesions have all been shown to be prevalent in patients with this instability pattern.37-40 It is typically the combination of multiple findings that predisposes the patient to recurrent posterior instability, and the treatment that is chosen must be pathology specific. It is often difficult to differentiate unidirectional posterior instability from multidirectional (posteroinferior, anterior/ posterior/inferior) instability because capsular laxity may be present in this patient population. The loadand-shift test, sulcus sign (in neutral and external
POSTERIOR INSTABILITY Posterior shoulder instability is an uncommon entity, occurring in 5% of all patients presenting with shoulder instability.32 Whereas a significant number of patients presenting with posterior shoulder instability may report trauma as the inciting cause, a number of patients may report episodes of subluxation when the arm is placed in a position of function.33 Recurrent posterior subluxation may be more common than frank posterior dislocation of the shoulder, with presenting signs and symptoms that are more vague (soreness or pain, shoulder fatigue with activity, and
FIGURE 6. Arthroscopic view of a left shoulder from the anterior portal (lateral decubitus position) showing a posterior labral tear in a patient with recurrent posterior subluxation.
ARTHROSCOPIC SHOULDER STABILIZATION TABLE 3.
Results of Open Posterior Shoulder Stabilization
Author Warren and colleagues47 Tibone and Bradley44 Bigliani et al.46 Hawkins and Janda45 Gerber and colleagues48 Misamore and Facibene49 Arciero and colleagues50 Total/mean
No. of Follow-up Recurrence Year Patients (mo) Rate 1989 1993 1995 1996 2000 2000
11 40 34 14 24 14
60 24-120 60 44 91 45
17% 40% 12% 0% 23% 7%
2005
12 149
40 59
8% 15%
rotation), circumduction test, jerk test, and Kim test all help to clearly delineate the pathology of posterior instability and have shown good reliability in the literature.41-43 The ability to address capsular redundancy, in addition to the labrum and rotator interval, increases the likelihood of a successful outcome in patients who are amenable to arthroscopic treatment.32 Historically, open posterior shoulder stabilization (in patients without osseous defects) has been fraught with unacceptably high recurrence rates in an active patient population. Arthroscopic treatment in this patient population is very promising, with results rivaling or surpassing those of anterior instability in very high-demand patients. Averaging the results of multiple studies in the literature gives an overall recurrence rate for open posterior capsular shift of 15%, with a range of 0% to 40% (Table 3).44-50 Although Hawkins and Janda45 showed a very low recurrence rate in their series, only 29% of patients were able to return to sports and only 1 contact athlete was included in the study. In a recent study by Rhee et al.,51 92.6% of patients undergoing an open posterior shift had a successful outcome; however, the recurrence rate was 13.3% when patients with voluntary subluxation were included in the final analysis. These results are comparable to those observed by Wolf et al.,52 with a recurrence rate of 19%. In patients who wish to return to collision sports or overhead throwing, these recurrence rates would be unacceptably high, and more modern arthroscopic approaches have significantly improved outcomes. There are multiple advantages of arthroscopic stabilization for recurrent posterior instability. As with anterior instability, the surgeon has the ability to address capsular laxity and tearing in addition to concomitant pathology, such as SLAP lesions, anterior labral tears, rotator interval lesions, and rota-
1427
tor cuff tears. In addition to posterior instability, the surgeon can also address multidirectional instability (MDI) with an “around-the-world” capsular plication when necessary, because these pathologies can commonly coexist. There is also less morbidity with an arthroscopic approach, and the results show superior outcomes, even in high-demand athletic patients. When reviewing studies evaluating modern arthroscopic techniques for the treatment of posterior shoulder instability (excluding studies that incorporated thermal capsulorrhaphy), we found recurrence rates ranging from 0% to 10%, with a mean of 5.3% (Table 4).53-57 In a direct comparison study of open versus arthroscopic posterior capsulorrhaphy, Arciero and colleagues50 found that functional outcomes were significantly improved in the patients who underwent arthroscopic fixation. In a review of 16 studies, Schepsis and colleagues58 compared arthroscopic and open techniques with regard to recurrence rates and return to sports and found no significant differences between groups; however, patients in the arthroscopic group reported higher satisfaction, and the arthroscopic studies analyzed did not include modern methods as reported in this review (no studies after 2004). Perhaps the greatest endorsement of arthroscopic posterior labral repair can be found from reviewing the data with regard to contact and throwing athletes, a subset of patients placing very high demands on the shoulder. In the study of Kim et al.,54 12 patients were contact athletes and 92% remained stable at final follow-up. Mair et al.59 evaluated 9 contact athletes after arthroscopic tack fixation of the posterior labrum and reported a 100% success rate at 2-year follow-up. In a study by one of us (J.P.B.), 51 contact athletes were included in the analysis of patients who underwent arthroscopic treatment for unidirectional posterior instability.55 Of these patients, 34 were football players (19 professional, 5 collegiate, and 10 high school), 7 TABLE 4.
Results of Arthroscopic Posterior Stabilization
Author Williams et al.53 Kim et al.54 Arciero and colleagues50 Bradley et al.55 Savoie et al.56 Snyder and colleagues57 Total/mean
No. of Follow-up Recurrence Year Patients (mo) Rate 2003 2003 2005 2006 2009 2010
26 27 19 91 131 29 323
61 39 40 48 28 66 47
7% 4% 10% 5% 3% 3% 5%
1428
F. P. TJOUMAKARIS AND J. P. BRADLEY MULTIDIRECTIONAL INSTABILITY
FIGURE 7. Arthroscopic view of a left shoulder from the posterior portal (lateral decubitus position) showing a “drive-through” sign with laxity of the anterior and inferior capsule. The humeral head and glenoid are barely visible in the same image in this patient with MDI.
were wrestlers, 6 played basketball, 2 played lacrosse, 1 played rugby, and 1 participated in martial arts. At 28 months’ follow-up, 94% of patients had good/excellent results by American Shoulder and Elbow Surgeons criteria and in 5 patients the procedure had failed (9.8%). Of the 5 patients in whom the stabilization procedure had failed, 4 underwent a capsular plication without suture anchors, implicating loss of fixation as a possible cause. In another study by the senior author (J.P.B.), 27 throwers underwent posterior instability repair at a mean follow-up of 27 months.60 At final follow-up, 89% of patients achieved good/excellent results based on the American Shoulder and Elbow Surgeons functional score, with 3 patients reporting failure during this time period. All 3 patients with failure were noted to have undergone posterior capsular plication without suture anchors, again raising the suspicion of loss of fixation as an etiologic factor. In an analysis of patients with type VIII SLAP lesions, which are commonly found in contact and throwing athletes, 100% of patients were able to return to sports after posterior and superior labral repair, with 69% of patients returning at their preinjury level.61 These most recent data show the superiority of arthroscopic treatment compared with historical open techniques in the absence of well-designed randomized trials (Video 1, available at www.arthroscopyjournal.org).
MDI has been a vexing problem for shoulder surgeons over the past several decades. Patients present with instability of the shoulder in several planes of motion and often have signs consistent with generalized ligamentous laxity. Although rehabilitation with rotator cuff and scapular muscle strengthening is the current gold standard of treatment after initial diagnosis, this regimen will fail in a significant number of patients.62 Treatment with open inferior capsular shift has been met with success in patients in whom a comprehensive physical therapy program fails.63 The validity of arthroscopic capsular shift was questioned in a recent study when it was found that an open capsular shift reduced shoulder volume better than an arthroscopic plication.64 The authors of that study found that open shift reduced capsular volume by 50% whereas arthroscopic methods were accompanied by a reduction of 22.8%. In a more recent study by Sekiya et al.,65 a multi-pleated arthroscopic capsular plication using suture anchors was found to be more effective in reducing capsular volume than traditional open means (58% reduction v 45% reduction) (Figs 7 and 8). Studies evaluating the success of arthroscopic capsular plication have shown excellent results in the current orthopaedic literature that rival the success of traditional open techniques.66-68 In a study evaluating the success of a modern suture anchor arthroscopic technique in high-demand athletes, the senior author (J.P.B.) found that 91% of the patients had full or
FIGURE 8. Arthroscopic view of a right shoulder from the anterior portal (lateral decubitus position) showing a multi-pleated plication of the posterior capsule in a patient with MDI.
ARTHROSCOPIC SHOULDER STABILIZATION
FIGURE 9. Coronal T2 magnetic resonance imaging sequence of a right shoulder showing humeral avulsion of the inferior glenohumeral ligament in a patient with recurrent anterior instability of the shoulder.
satisfactory range of motion and 86% of the athletes were able to return to their previous level of sport.69 Despite the comparable success rates of arthroscopic and open capsular shift in patients with MDI, we currently advocate an all-arthroscopic approach. A significant number of patients with MDI will also have findings consistent with posterior instability (Kim lesions, posterior labral tears, and so on), and an open anterior approach makes addressing this concomitant pathology challenging. In addition, because MDI is not routinely associated with bony deficiency, the ability to perform an anterior and posterior pan-capsular plication arthroscopically addresses the full spectrum of instability in this patient population. With suture anchors supplanting suture-only repair as the more preferred method in recent studies, patients who place high demands on their shoulders are ever increasing their ability to return to high-level activities and sports. OTHER CONSIDERATIONS (HAGL, CONTACT ATHLETES) As our understanding of the complex nature of shoulder instability has evolved, so has our ability to treat the spectrum of disease. With high-resolution magnetic resonance imaging and arthrogram evaluation, avulsion of the glenohumeral ligaments from the
1429
humerus is increasingly recognized as a significant source of morbidity.7 Currently, HAGL lesions are considered among the most difficult lesions to address arthroscopically (Fig 9). Although we still use an open approach as our preferred method of treatment for adequate visualization, we recognize the success of several authors in the ability to repair these lesions arthroscopically.70-72 Typically, a 70° arthroscope is used to visualize the insertion of the inferior glenohumeral ligaments on the humerus, and an inferior accessory portal is used to ensure anatomic placement of the suture anchor within the insertion site. As mentioned previously, contact and collision athletes are a patient population that is predisposed to a high recurrence rate after stabilization based on the high demands placed on the shoulder during these activities. The high-energy nature of subluxation and dislocation events in football, rugby, and hockey can result in significant bony and soft-tissue damage. Because of this, contact athletes are prone to higher dislocation rates after anterior stabilization procedures.73,74 We believe that contact athletes with capsular laxity and disruption of the capsulolabral complex without bony lesions can be treated successfully with modern arthroscopic methods. In a study by Mazzocca et al.,75 100% of contact athletes treated with arthroscopic stabilization were able to return to organized high school or collegiate sports. This study supports the thesis that adherence to modern principles of reducing capsular laxity, using suture anchors, and addressing concomitant pathology (rotator interval laxity) can result in favorable outcomes in cases that were traditionally treated with an open technique. DISCUSSION The majority of patients who present with shoulder instabilities can be treated by an all-arthroscopic apTABLE 5.
Contraindications to Arthroscopic Shoulder Repair
Patient-Related Factors Medically unstable patient Uncontrolled seizure disorder Collagen disorders (Marfan syndrome, Ehlers-Danlos syndrome) Secondary gain or voluntary subluxation
Surgical Factors/Decision Making Engaging Hill-Sachs defects (ⱖ30% of humeral head) Significant glenoid bone defects (ⱖ25%) Capsular deficiency (prior thermal capsulorrhaphy) Presence of HAGL lesions (relative contraindication)
1430
F. P. TJOUMAKARIS AND J. P. BRADLEY
TABLE 6.
Pearls and Pitfalls of Arthroscopic Shoulder Stabilization
Pearls (Figs 10–12) Preoperative computed tomography scan may help clearly define size of bone defects.
The lateral decubitus position may offer easier access to the posterior labrum.
Plication of the inferior capsule and the use of 3 or more anchors help to lessen the rate of recurrence in anterior instability.
Pitfalls Placing the anchors on the glenoid neck (rather than the face) may not adequately restore the length/tension relation of the glenohumeral ligaments. Failure to recognize and treat concomitant laxity of the posterior/anterior/superior capsule may increase the likelihood of recurrence (of both instability and symptoms). For Bankart repair, the first anchor is traditionally placed low on the glenoid face (below the 5-o’clock position).
proach. Whereas a subset of patients may require open treatment because of osseous defects and deformities about the shoulder, the absolute contraindications to arthroscopic stabilization are dwindling (Table 5). Arthroscopic treatment offers the advantage of a minimally invasive approach with less soft-tissue scarring, restriction in motion, and subscapularis failure. In addition, the ability to simultaneously address con-
FIGURE 10. Arthroscopic view from the posterior portal of a right shoulder (lateral decubitus position) showing elevation of the torn labrum/capsule from the glenoid neck.
FIGURE 11. Arthroscopic view from the posterior portal of a left shoulder (lateral decubitus position) showing placement of the first anchor low on the face of the glenoid (below the 5-o’clock position).
comitant pathology such as SLAP lesions, rotator interval lesions, and posterior and inferior capsular laxity places the arthroscope at the top of our treatment pyramid. Current studies comparing an evolved arthroscopic technique with traditional open means show equivalent or better outcomes, particularly in
FIGURE 12. Arthroscopic view from the anterior portal of a right shoulder (lateral decubitus position) showing restoration of the capsulolabral complex to the anterior glenoid rim.
ARTHROSCOPIC SHOULDER STABILIZATION athletes. With recent advances in musculoskeletal imaging, preoperative planning has become paramount in understanding the complex and multifactorial nature of shoulder instability. Patients are rarely believed to have unidirectional instability today, and recognition of the full spectrum of instability, which can include elements of MDI, has become more prevalent among shoulder-trained surgeons (Table 6). With these advancements in diagnosis comes a better understanding of arthroscopic means of fixation. With modern techniques that use multiple suture anchors aimed at reducing capsular and ligamentous laxity, we are able to achieve stability that was previously believed to only occur after open stabilization. This is perhaps most beneficial to our athletic patients who are determined to return to their previous level of play without morbidity or restriction in shoulder range of motion (Figs 10 –12). Current arthroscopic techniques have evolved to where arthroscopy should be the preferred method of repair for anterior instability, posterior instability, and MDI, because the results show equal stability, better motion, improved functional outcomes, and most importantly, return to sports.
11.
12.
13. 14. 15.
16. 17.
18.
19.
REFERENCES 20. 1. Green MR, Christensen KP. Arthroscopic versus open Bankart procedures: A comparison of early morbidity and complications. Arthroscopy 1993;9:371-374. 2. Sisto DJ, Cook DL. Intraoperative decision making in the treatment of shoulder instability. Arthroscopy 1998;14:389394. 3. Stein DA, Jazrawi L, Bartolozzi AR. Arthroscopic stabilization of anterior shoulder instability: A review of the literature. Arthroscopy 2002;18:912-924. 4. Hobby J, Griffin D, Dunbar M, Boileau P. Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations. J Bone Joint Surg Br 2007;89:1188-1196. 5. Owens CB, Nelson BJ, Duffey ML, et al. Pathoanatomy of first-time, traumatic, anterior glenohumeral subluxation events. J Bone Joint Surg Am 2010;92:1605-1611. 6. Rothberg DL, Burks RT. Capsular tear in line with the inferior glenohumeral ligament: A cause of anterior glenohumeral instability in 2 patients. Arthroscopy 2009;25:934-936. 7. Wolf EM, Cheng JC, Dickson JC. Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability. Arthroscopy 1995;11:600-607. 8. Antonio GE, Griffith JF, Yu AB, Yung PS, Chan KM, Ahuja AT. First-time shoulder dislocation: High prevalence of labral injury and age-related differences revealed by MR arthrography. J Magn Reson Imaging 2007;26:983-991. 9. Rowe CR, Zarins B, Ciullo JV. Recurrent anterior dislocation of the shoulder after surgical repair. Apparent causes of failure and treatment. J Bone Joint Surg Am 1984;66:159-168. 10. Sekiya JK, Wickwire AC, Stehle JH, Debski RE. Hill-Sachs defects and repair using osteoarticular allograft transplanta-
21.
22.
23. 24. 25. 26.
27. 28. 29.
1431
tion: Biomechanical analysis using a joint compression model. Am J Sports Med 2009;37:2459-2466. 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: 677-694. Itoi E, Lee SB, Amrami KK, Wenger DE, An KN. Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography. Am J Sports Med 2003;31:112-118. Lafosse L, Boyle S. Arthroscopic Latarjet procedure. J Shoulder Elbow Surg 2010;19:2-12. Purchase RJ, Wolf EM, Hobgood ER, Pollock ME, Smalley CC. Hill-Sachs “remplissage”: An arthroscopic solution for the engaging Hill-Sachs lesion. Arthroscopy 2008;24:723-726. Skendzel JG, Sekiya JK. Arthroscopic glenoid osteochondral allograft reconstruction without subscapularis takedown: Technique and literature review. Arthroscopy 2011;27:129135. Boileau P, Richou J, Lisai A, Chuinard C, Bicknell RT. The role of arthroscopy in revision of failed open anterior stabilization of the shoulder. Arthroscopy 2009;25:1075-1084. Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V. Arthroscopic salvage of failed arthroscopic Bankart repair: A prospective study with a minimum follow-up of 4 years. Am J Sports Med 2008;36:1330-1336. 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. 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. Freedman KB, Smith AP, Romeo AA, Cole BJ, Bach BR. 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. Mohtadi NG, Bitar IJ, Sasyniuk TM, Hollinshead RM, Harper WP. Arthroscopic versus open repair for traumatic anterior shoulder instability: A meta-analysis. Arthroscopy 2005;21: 652-658. Boileau P, Villalba M, Héry 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: 1755-1763. Kim SH, Ha KI, Kim SH. Bankart repair in traumatic anterior shoulder instability: Open versus arthroscopic technique. Arthroscopy 2002;18:755-763. Kim SH, Ha KI, Cho YB, Ryu BD, Oh I. Arthroscopic anterior stabilization of the shoulder: Two- to six-year follow-up. J Bone Joint Surg Am 2003;85:1511-1518. Tjoumakaris FP, Abboud JA, Hasan SA, Ramsey ML, Williams GR. Arthroscopic and open Bankart repairs provide similar outcomes. Clin Orthop Relat Res 2006;446:227-232. 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. Pulavarti RS, Symes TH, Rangan A. Surgical interventions for anterior shoulder instability in adults. Cochrane Database Syst Rev 2009;4:CD005077. Petrera M, Patella V, Patella S, et al. A meta-analysis of open versus arthroscopic Bankart repair using suture anchors. Knee Surg Sports Traumatol Arthrsoc 2010;18:1742-1747. Sachs RA, Williams B, Stone ML, Paxton L, Kuney M. Open
1432
30. 31. 32. 33. 34.
35. 36.
37. 38.
39.
40.
41. 42. 43. 44. 45. 46.
47. 48. 49.
50.
F. P. TJOUMAKARIS AND J. P. BRADLEY
Bankart repair: Correlation of results with postoperative subscapularis function. Am J Sports Med 2005;33:1458-1462. Wang C, Ghalambor N, Zarins B, Warner JJ. Arthroscopic versus open Bankart repair: Analysis of patient subjective outcome and cost. Arthroscopy 2005;21:1219-1222. Barber FA, Click SD, Weideman CA. Arthroscopic or open Bankart procedures: What are the costs? Arthroscopy 1998; 14:671-674. Robinson CM, Aderinto J. Recurrent posterior shoulder instability. J Bone Joint Surg Am 2005;87:883-892. Arciero RA, Mazzocca AD. Traumatic posterior shoulder subluxation with labral injury: Suture anchor technique. Tech Shoulder Elbow Surg 2004;5:13-24. Wirth MA, Seltzer DG, Rockwood CA Jr. Recurrent posterior glenohumeral dislocation associated with increased retroversion of the glenoid. A case report. Clin Orthop Relat Res 1994:98-101. Modi CS, Wicks L, Srinivasan K. Reconstruction of humeral head defect for locked posterior shoulder dislocation. Orthopedics 2009;32:691. Gerber C, Lambert SM. 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 1996;78:376-382. Harryman DT II, Sidles JA, Harris SL, Matsen FA. The role of the rotator interval capsule in passive motion and stability of the shoulder. J Bone Joint Surg Am 1992;74:53-66. Kim SH, Noh KC, Park JS, Ryu BD, Oh I. Loss of chondrolabral containment of the glenohumeral joint in atraumatic posteroinferior multidirectional instability. J Bone Joint Surg Am 2005;87:92-98. Kim SH, Ha KI, Yoo JC, Noh KC. Kim’s lesion: An incomplete and concealed avulsion of the posteroinferior labrum in posterior or multidirectional posteroinferior instability of the shoulder. Arthroscopy 2004;20:712-720. Safran O, Defranco MJ, Hatem S, Iannotti JP. Posterior humeral avulsion of the glenohumeral ligament as a cause of posterior shoulder instability. A case report. J Bone Joint Surg Am 2004;86:2732-2736. Kim SH, Park JC, Park JS, Oh I. Painful jerk test: A predictor of success in nonoperative treatment of posteroinferior instability of the shoulder. Am J Sports Med 2004;32:1849-1855. Kim SH, Park JS, Jeong WK, Shin SK. The Kim test: A novel test for posteroinferior labral lesion of the shoulder—A comparison to the jerk test. Am J Sports Med 2005;33:1188-1192. Tzannes A, Paxinos A, Callanan M, Murrell GA. An assessment of the interexaminer reliability of tests for shoulder instability. J Shoulder Elbow Surg 2004;13:18-23. Tibone JE, Bradley JP. The treatment of posterior subluxation in athletes. Clin Orthop Relat Res 1993:124137. Hawkins RJ, Janda DH. Posterior instability of the glenohumeral joint. A technique of repair. Am J Sports Med 1996;24: 275-278. Bigliani LU, Pollock RG, McIlveen SJ, Endrizzi DP, Flatow EL. Shift of the posteroinferior aspect of the capsule for recurrent posterior glenohumeral instability. J Bone Joint Surg Am 1995;77:1011-1020. Fronek J, Warren RF, Bowen M. Posterior subluxation of the glenohumeral joint. J Bone Joint Surg Am 1989;71:205-216. Fuchs B, Jost B, Gerber C. Posterior-inferior capsular shift for the treatment of recurrent, voluntary posterior subluxation of the shoulder. J Bone Joint Surg Am 2000;82:16-25. Misamore GW, Facibene WA. Posterior capsulorrhaphy for the treatment of traumatic recurrent posterior subluxations of the shoulder in athletes. J Shoulder Elbow Surg 2000;9:403408. Bottoni CR, Franks BR, Moore JH, DeBerardino TM, Taylor DC, Arciero RA. Operative stabilization of posterior shoulder instability. Am J Sports Med 2005;33:996-1002.
51. Rhee YG, Lee DH, Lim CT. Posterior capsulolabral reconstruction in posterior shoulder instability: Deltoid saving. J Shoulder Elbow Surg 2005;14:355-360. 52. Wolf BR, Strickland S, Williams RJ, Allen AA, Altchek DW, Warren RF. Open posterior stabilization for recurrent posterior glenohumeral instability. J Shoulder Elbow Surg 2005;14: 157-164. 53. Williams RJ III, Strickland S, Cohen M, Altchek DW, Warren RF. Arthroscopic repair for traumatic posterior shoulder instability. Am J Sports Med 2003;31:203-209. 54. Kim SH, Ha KI, Park JH, et al. Arthroscopic posterior labral repair and capsular shift for traumatic unidirectional recurrent posterior subluxation of the shoulder. J Bone Joint Surg Am 2003;85:1479-1487. 55. Bradley JP, Baker CL III, Kline AJ, Armfield DR, Chhabra A. Arthroscopic capsulolabral reconstruction for posterior instability of the shoulder: A prospective study of 100 shoulders. Am J Sports Med 2006;34:1061-1071. 56. Savoie FH III, Holt MS, Field LD, et al. Arthroscopic management of posterior instability: Evolution of technique and results. Arthroscopy 2009;24:389-396. 57. Bahk MS, Karzel RP, Snyder SJ. Arthroscopic posterior stabilization and anterior capsular plication for recurrent posterior glenohumeral instability. Arthroscopy 2010;26:1172-1180. 58. Kakar S, Voloshin I, Kaye EK, et al. Posterior shoulder instability: Comprehensive analysis of open and arthroscopic approaches. Am J Orthop 2007;36:655-659. 59. Mair SD, Zarzour RH, Speer KP. Posterior labral injury in contact athletes. Am J Sports Med 1998;26:753-758. 60. Radkowski CA, Chhabra A, Baker CL III, Tejwani SG, Bradley JP. Arthroscopic capsulolabral repair for posterior shoulder instability in throwing athletes compared with nonthrowing athletes. Am J Sports Med 2008;36:693-699. 61. Seroyer S, Tejwani SG, Bradley JP. Arthroscopic capsulolabral reconstruction of the type VIII superior labrum anterior posterior lesion: Mean 2-year follow-up on 13 shoulders. Am J Sports Med 2007;35:1477-1483. 62. Misamore GW, Sallay PI, Didelot W. A longitudinal study of patients with multidirectional instability of the shoulder with seven- to ten-year follow-up. J Shoulder Elbow Surg 2005;14: 466-470. 63. Neer CS II, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am 1980;62:897-908. 64. Cohen SB, Wiley W, Goradia VK, Pearson S, Miller MD. Anterior capsulorrhaphy: An in vitro comparison of volume reduction—Arthroscopic plication versus open capsular shift. Arthroscopy 2005;21:659-664. 65. Sekiya JK, Willobee JA, Miller MD, Hickman AJ, Willobee A. Arthroscopic multi-pleated capsular plication compared with open inferior capsular shift for reduction of shoulder volume in a cadaveric model. Arthroscopy 2007;23:11451151. 66. 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. 67. Treacy SH, Savoie FH III, Field LD. Arthroscopic treatment of multidirectional instability. J Shoulder Elbow Surg 1999;8: 345-350. 68. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of bidirectional glenohumeral instability: Two- to five-year follow-up. J Shoulder Elbow Surg 2001;10:28-36. 69. Baker CL III, Mascarenhas R, Kline AJ, Chhabra A, Pombo MW, Bradley JP. Arthroscopic treatment of multidirectional shoulder instability in athletes: A retrospective analysis of 2to 5-year clinical outcomes. Am J Sports Med 2009;37:17121720.
ARTHROSCOPIC SHOULDER STABILIZATION 70. Kon Y, Shiozaki H, Sugaya H. Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion. Arthroscopy 2005;21:632.e1-632.e6. 71. Richards DP, Burkhart SS. Arthroscopic humeral avulsion of the glenohumeral ligaments (HAGL) repair. Arthroscopy 2004;20:134-141. 72. Chhabra A, Diduch DR, Anderson M. Arthroscopic repair of a posterior humeral avulsion of the inferior glenohumeral ligament (HAGL) lesion. Arthroscopy 2004;20:73-76 (Suppl). 73. Uhorchak JM, Arciero RA, Huggard D, Taylor DC. Recurrent
1433
shoulder instability after open reconstruction in athletes involved in collision and contact sports. Am J Sports Med 2000;28:794-799. 74. Pagnani MJ, Dome DC. Surgical treatment of traumatic anterior shoulder instability in American football players. J Bone Joint Surg Am 2002;82:711-715. 75. Mazzocca AD, Brown FM, Carreira DS, Hayden J, Romeo AA. Arthroscopic anterior shoulder stabilization of collision and contact athletes. Am J Sports Med 2005;33: 52-60.