Arthroscopic stabilization of anterior shoulder instability: a historical perspective

The role of arthroscopic procedures in the management of glenohumeral instability continues to evolve and represents an effective alternative for addressing the pathology associated with this condition. Patient selection criteria, operative techniques, and implants all continue to evolve and have resulted in improved rates of success. Arthroscopic procedures benefit patients by avoiding the common morbidities associated with the disruption of the anterior soft tissues, including a loss of external rotation associated with open procedures. Arthroscopic procedures remain technically demanding and require skills to address all of the existing pathology. The surgeon must be prepared to address many conditions beyond the Bankart lesions including glenoid bone lesions. capsular laxity, rotator interval lesions, and SLAP lesions. In addition to the documentation of recurrence, the success of this procedure must be evaluated within the context of retained ranges of motion, recovery time, proprioceptive control, and the return to prior levels of activity. Further studies are necessary to continue to validate the efficacy of arthroscopic stabilization.     

Open and arthroscopic techniques for the treatment of traumatic anterior shoulder instability in Australian rules football players.

Australian Rules football (ARF) is a potentially violent, overhead, body-contact sport. We reviewed 56 shoulders in patients who sustained their initial traumatic anterior subluxation or dislocation during ARF and who underwent reconstructive surgery for traumatic anterior instability, whether by arthroscopic or by open techniques. Patients were followed up for a mean of 29.4 months after operation, and clinical evaluation was performed with the Rowe grading system. Three types of surgical procedures were performed: arthroscopic suture repair, arthroscopic Bankart repair with an absorbable polyglyconate tack, and open capsular shift with repair of the Bankart lesion. Shoulders treated with arthroscopic suture repair had a 70% rate of recurrent subluxation or dislocation on return to ARF Dislocations treated arthroscopically with the biodegradable tack had a 38% rate of recurrence of instability; three fourths of the recurrences were after minimal to moderate trauma. Shoulders treated with an open capsular shift and Bankart procedure had a 30% rate of recurrent instability, with half of the recurrences caused by violent trauma. In the open group there were no failures in patients who did not return to ARF. We suggest that arthroscopic repair in shoulders with anterior instability and recurrent dislocation does not adequately address the plastic deformation of the anterior capsule that may occur after repeated episodes of dislocation. We advocate open shoulder procedures in ARF athletes to address all areas of the capsulolabral pathologic condition and to provide the most secure repair possible with minimal chance of recurrence.     

Comparison of arthroscopic and open anterior shoulder stabilization. A two to six-year follow-up study

BACKGROUND: Sixty-three consecutive patients with recurrent traumatic anterior shoulder instability underwent operative repair. The decision to select either arthroscopic Bankart repair or open capsular shift was based on the findings of an examination under anesthesia and the findings at the time of arthroscopy. Thirty-nine patients with only anterior translation on examination under anesthesia and a discrete Bankart lesion underwent arthroscopic Bankart repair with use of absorbable transfixing implants. Twenty-four patients with inferior translation in addition to anterior translation on examination under anesthesia and capsular laxity or injury on arthroscopy underwent an open capsular shift. METHODS: Treatment outcomes for each group were determined according to the scoring systems of Rowe et al., the American Shoulder and Elbow Surgeons, and the Short Form-36. Failure was defined as recurrence of dislocation or subluxation or the finding of apprehension. Fifty-nine (94 percent) of the sixty-three patients were examined and filled out a questionnaire at a mean of fifty-four months (range, twenty-seven to seventy-two months) following surgery. RESULTS: There were no significant differences between the two groups with regard to the prevalence of failure or any of the other measured parameters of outcome. An unsatisfactory outcome occurred after nine (24 percent) of thirty-seven arthroscopic repairs and after four (18 percent) of twenty-two open reconstructions. All cases of recurrent instability resulted from a reinjury in a contact sport or a fall less than two years postoperatively. The treatment groups did not differ with regard to patient age, hand dominance, mechanism of initial injury, duration of follow-up, or delay until surgery. Measured losses of motion were minimal and, with the exception of forward elevation, slightly more of which was lost after the open capsular shifts (p = 0.05), did not differ between the two forms of treatment. Approximately 75 percent of the patients in each group returned to their favorite recreational sports with no or mild limitations. As rated by the patients, the result was good or excellent after thirty-one (84 percent) of the arthroscopic procedures and after twenty (91 percent) of the open procedures. CONCLUSIONS: Arthroscopic and open repair techniques for the treatment of recurrent traumatic shoulder instability yield comparable results if the procedure is selected on the basis of the pathological findings at the time of surgery.     

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

A systematic search of the literature published between January 1985 and February 2006 identified 62 studies which reported the results of arthroscopic procedures for chronic anterior shoulder instability or comparisons between arthroscopic and open surgery. These studies were classified by surgical technique and research methodology, and when appropriate, were included in a meta-analysis. The failure rate of arthroscopic shoulder stabilisation using staples or transglenoid suture techniques appeared to be significantly higher than that of either open surgery or arthroscopic stabilisation using suture anchors or bio-absorbable tacks. Arthroscopic anterior stabilisation using the most effective techniques has a similar rate of failure to open stabilisation after two years.     

Results and factors affecting outcome of revision surgery for shoulder instability

We conducted a clinical study identifying the causes of failure and the variables affecting outcome in 28 patients with failed open or arthroscopic anterior shoulder reconstruction for anterior glenohumeral instability. All patients underwent an open revision stabilization procedure. Surgical outcomes at a minimum 24 months' follow-up were available in 25 patients. The most common findings at revision surgery were capsular redundancy and Bankart lesions. Satisfactory results were found in 21 patients (84%) after repeat instability surgery. Factors contributing to negative outcome were glenohumeral arthritis, age greater than 30 years, 2 or more previous instability procedures, a bony Bankart lesion, the diagnosis of multidirectional instability, and surgery involving the nondominant arm (P < .05). Revision shoulder stabilization can be successful when the correct diagnosis is made and appropriate surgery performed. However, the outcome is less predictable in patients with multiple previous surgeries.     

Anteriore Glenoidranddefekte der Schulter

Bony instability of the shoulder due to glenoid defects has recently received increasing attention. Glenoid defects can be divided into acute fragment-type lesions (type I), chronic fragment-type lesions (type II) and glenoid bone loss without a bony fragment (type III). The diagnosis and classification are mainly based on imaging methods including a radiographic instability series and/or computed tomography. The management of anterior glenoid rim lesions depends on many factors including the clinical presentation, type of lesion, concomitant pathology as well as age and functional demands of the patient. If bony-mediated instability is present, surgery is indicated. In the majority of cases fragment-type lesions can be successfully treated using either arthroscopic or open reconstruction techniques. Small erosion-type lesions can also be managed via soft-tissue procedures, whereas large erosion-type lesions with significant bone loss may necessitate bone-grafting procedures (autologous iliac crest or coracoid transfer) to restore glenoid concavity and shoulder stability. Although glenoid bone grafting is usually performed via an open approach, recent clinical studies have shown that it can be successfully managed by advanced arthroscopic techniques.     

Volumetric change in the shoulder capsule after open inferior capsular shift versus arthroscopic thermal capsular shrinkage: a cadaveric model

The purpose of this study was to compare the percentage of glenohumeral intracapsular volume reduction after open inferior capsular shift and arthroscopic thermal capsulorrhaphy. Twelve matched, fresh-frozen cadaveric shoulders were used for the study. Intraarticular glenohumeral volume measurements were obtained by injecting a viscous fatty acid sulfate solution into the joint. In the 6 right shoulders, a standard anterior-inferior capsular shift was performed, and in the 6 matching left shoulders, an arthroscopic thermal capsular shrinkage was performed. After the procedures, the capsular volumes were re-measured. The open inferior shift procedure resulted in a mean decrease in glenohumeral volume of 50.2% (range, 43%-56%). Arthroscopic thermal capsulorrhaphy decreased shoulder intraarticular volume by a mean of 29.7% (range, 26%-36%). Both the open capsular shift and arthroscopic thermal shrinkage procedures produced well-documented volumetric reductions in the shoulder capsules. The open shift reduced intraarticular shoulder volume significantly more than arthroscopic thermal capsular shrinkage.     

Arthroscopic shoulder stabilization with suture anchors: technique, technology, and pitfalls

Arthroscopic treatment of anterior shoulder instability has evolved significantly during the past decade. Currently, most techniques include the use of suture and suture anchors. A successful outcome is highly dependent on accurate patient selection. Preoperative evaluation, examination with the patient under anesthesia, and defining the pathoanatomy by a thorough arthroscopic examination determine the most effective treatment strategy. Technical skills include the surgeon's ability to accomplish anchor placement, suture passage, and arthroscopic knot tying. Various instruments and techniques are available to facilitate arthroscopic reconstruction. In properly selected patients and with good surgical technique, outcomes should approximate or exceed traditional open stabilization techniques.     

Arthroscopic capsular shift technique and volume reduction

Multidirectional instability is very complex pathology. Excessively redundant capsule is one of the important reasons causing symptomatic laxity in multiple planes. Arthroscopic techniques are not able to reproduce the potential of open methods to reduce the joint volume. Most of the studies based their measurements on cadaver model. The aim of the study was to develop simple and reproducible technique to perform arthroscopic capsular shift and measure its volume reduction potential in both cadaveric and clinical setting. Technique is described in the paper. Capsular shift was applied both in cadaver and clinical scenario. Based on group of 5 cadaver shoulder specimen, glenohumeral joint volume was reduced from average of 19.4?±?7.8?ml to 11.9?±?4.5?ml following arthroscopic capsular shift (37.9% volume reduction). Clinical material consisted of 12 consecutive patients shoulder with instability and joint laxity undergoing the arthroscopic capsular shift. Average glenohumeral volume before capsular shift was 43.5?±?10?ml and was reduced to 17.5?±?4.3?ml (58.8% volume reduction). Arthroscopic capsular shift presented in this paper seems to be relatively easy to perform and safe procedure. The technique provides significant decrease in joint volume in both cadaveric and clinical parts of the study. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s00590-011-0865-z) contains supplementary material, which is available to authorized users.     

Traumatic Shoulder Dislocation With Combined Bankart Lesion and Humeral Avulsion of the Glenohumeral Ligament in a Professional Basketball Player: Three-Year Follow-up of Surgical Stabilization

Traumatic anterior shoulder instability has been well documented to have associated lesions such as a Bankart tear, humeral avulsion of the glenohumeral ligament (HAGL), Hill-Sachs lesion, fracture, and nerve injury. To our knowledge, the combined Bankart and HAGL injury in a single acute anterior shoulder dislocation has not yet been reported. We describe a traumatic first-time anterior-inferior shoulder dislocation in a professional basketball player with a combined Bankart and HAGL lesion. The patient underwent arthroscopic Bankart repair followed by open repair of the HAGL lesion with an open capsular shift reconstruction. At 3 years' follow-up, the patient had returned to an elite level of play, with an excellent outcome.     

Arthroscopic treatment of multidirectional instability.

Multidirectional instability of the shoulder, described by Neer and Foster, has been treated surgically with the inferior capsular shift procedure. The small number of reports on mid-term outcomes indicate that good to excellent results have been obtained in 75% to 100% of cases. Arthroscopic treatment of multidirectional instability has been previously described. The purpose of this study was to review the results of the arthroscopic capsular shift procedure with a minimum follow-up of 2 years. A retrospective study was performed on 25 patients who underwent an arthroscopic capsular shift performed with the transglenoid technique between January 1990 and December 1993. All patients had earlier not responded to an extensive course of physical therapy. Excluded from the study were patients who had undergone a previous arthroscopic capsular shift or any other procedure, arthroscopic or open, for the shoulder. Average patient age was 26.4 years. There were 20 male and 5 female patients. Sixteen of the affected shoulders involved the dominant extremity. All patients had a history of asymptomatic subluxation that slowly progressed to symptomatic subluxation. Eleven patients had a history of dislocation. Thirteen patients were athletes who were symptomatic in their chosen sport, whereas the other patients were symptomatic in activities of daily living. All patients were examined while they were under anesthesia and had positive results on the sulcus test in abduction with associated anterior instability, posterior instability, or both. Follow-up evaluation was performed with patient interview and examination. All 25 patients were available for follow-up, which occurred an average of 60 months (range 36 to 80 months) after operation. Three patients had episodes of instability after the operation. The average Bankart score was 95 (range of 50 to 100). All but 1 patient had regained full symmetric range of motion by follow-up. Twenty-one (88%) patients had a satisfactory result according to the Neer system. Results of treatment with the arthroscopic capsular shift procedure for multidirectional instability of the shoulder appear to be comparable to those of the open inferior capsular shift.     

Arthroscopic Bankart repair with the Suretac device for traumatic anterior shoulder instability in athletes

Arthroscopic treatment of anterior shoulder instability in the athlete has evolved tremendously over the past decade. Currently, most techniques include the use of suture and suture anchors. However, the variety of arthroscopic instruments and techniques that are available shows the complexity of intra-articular tissue fixation, which includes anchor placement, suture passing, and knot tying. Stabilization using the Suretac device (Acufex Microsurgical, Mansfield, MA) simplifies tissue fixation by eliminating the need for arthroscopic suture passing and intra-articular knot tying. However, a successful outcome is highly dependent on accurate patient selection. Preoperative evaluation, examination under anesthesia, and the pathoanatomy defined by a thorough arthroscopic examination suggest the most effective treatment strategy. The ideal candidate for shoulder stabilization using the Suretac device is an athlete with a relatively pure traumatic anterior instability pattern with detachment pathology (e.g., Bankart lesion) and minimal capsular deformation.     

Revision arthroscopic capsulolabral reconstruction for recurrent instability of the shoulder

We have investigated the outcome of arthroscopic revision surgery for recurrent instability of the shoulder after failed primary anterior stabilisation. We identified 40 patients with failed primary open or arthroscopic anterior stabilisation of the shoulder who had been treated by revision arthroscopic capsulolabral reconstruction and followed up for a mean of 36 months (12 to 87). There were 34 men and six women with a mean age of 33.1 years (15 to 48). Details of the patients, the technique of the primary procedure, the operative findings at revision and the clinical outcome were evaluated by reviewing the medical records, physical examination and the use of the Western Ontario shoulder instability index score, the American Shoulder and Elbow Surgeons score and the health status questionnaire 12. Recurrent instability persisted in four patients after the revision arthroscopic procedure. At the final follow-up, the mean American Shoulder and Elbow Surgeons score was 81.1 (17.5 to 99.5) and the mean Western Ontario shoulder instability index score was 68.2 (20 to 98.2). Quality-of-life scoring showed good to excellent results in most patients. Arthroscopic revision capsulolabral reconstruction can provide a satisfactory outcome in selected patients for recurrent instability of the shoulder provided that no large Hill-Sachs lesion is present.     

Editorial Commentary: Arthroscopic Glenoid Reconstruction With Subscapularis Tenodesis Results in Promising Clinical Outcomes,but Concerns Regarding Graft Resorption Rates Persist: A Long Way Toward a More Perfect Union

The pros and cons of open and arthroscopic shoulder stabilization procedures have been studied exhaustively. Yet, in many situations, the rates of recurrent instability and overall complications associated with these techniques remain unacceptably high. Perhaps paradoxically, the refinement of arthroscopic shoulder stabilization techniques has only intensified the debate between proponents of either open or arthroscopic approaches, and although significant (however “significant” is defined), anteroinferior glenoid bone loss has historically been thought to constitute a relatively strong indication for an open bone augmentation procedure, surgeons, to their great credit, continue to push the limits of what can be accomplished arthroscopically. Arthroscopic glenoid reconstruction has emerged as a viable option that may represent “the best of both worlds.” Although modifications to the originally described arthroscopic glenoid reconstruction technique are promising, concerns persist regarding the fate of the graft and the durability of the procedure beyond short-term follow-up.     

The Hill-Sachs lesion: diagnosis, classification, and management

The Hill-Sachs lesion is an osseous defect of the humeral head that is typically associated with anterior shoulder instability. The incidence of these lesions in the setting of glenohumeral instability is relatively high and approaches 100% in persons with recurrent anterior shoulder instability. Reverse Hill-Sachs lesion has been described in patients with posterior shoulder instability. Glenoid bone loss is typically associated with the Hill-Sachs lesion in patients with recurrent anterior shoulder instability. The lesion is a bipolar injury, and identification of concomitant glenoid bone loss is essential to optimize clinical outcome. Other pathology (eg, Bankart tear, labral or capsular injuries) must be identified, as well. Treatment is dictated by subjective and objective findings of shoulder instability and radiographic findings. Nonsurgical management, including focused rehabilitation, is acceptable in cases of small bony defects and nonengaging lesions in which the glenohumeral joint remains stable during desired activities. Surgical options include arthroscopic and open techniques.     

Recurrent anterior shoulder instability associated with bony defects

Mobility of the glenohumeral joint is facilitated through the complex interplay of soft tissue and osseous anatomy. Arthroscopic shoulder stabilization is commonly used in the surgical management of shoulder instability. However, the management of the unstable shoulder associated with bony defects (glenoid, humeral, or combined) can be challenging. Adequate recognition of bony defects is paramount to successful treatment and entails a careful history, clinical examination, and advanced radiographic imaging. Nonoperative methods of treatment are often insufficient for treating patients with large bony defects. Bony procedures, as opposed to soft procedures, may yield better outcomes in this patient population. However, respective surgical techniques used to address these defects are technically challenging with a significant learning curve and may lead to significant morbidity. This represents a paradigm shift in treatment and replaces the old paradigm of "open vs arthroscopic" instability surgery.     

Shoulder arthroscopy: current indications and techniques

The role of arthroscopy in the diagnosis and treatment of shoulder disorders is evolving. Arthroscopic subacromial decompression is an alternative to open anterior acromioplasty in the treatment of chronic stage II impingement syndromes prior to the development of full thickness rotator cuff tear. Patients with massive and otherwise unrepairable cuff tears have achieved significant pain relief from arthroscopic decompression and debridement of the floppy and irregular cuff margins. Routine repairable full thickness cuff tears are best treated by open reconstruction. The arthroscope is an adjunct in confirming the diagnosis and direction of shoulder instability. Arthroscopic stabilization is most feasible when the anterior glenohumeral ligament/labral complex is detached. The introduction of a metal staple is controversial, however, reported complications are diminishing with experience. Alternate methods of stabilization are being investigated. Effective arthroscopic techniques have been established for the removal of loose bodies, the treatment of calcific tendinitis, septic arthritis, and other disorders. Shoulder arthroscopy will undoubtedly achieve an appropriate place in the armamentarium of the orthopedic surgeon.     

Posterior instability

Posterior shoulder instability is a pathology that is increasingly seen in athletes. Excessive capsular laxity was originally proposed as the key component. Recent cadaveric and arthroscopic work has identified the importance of glenolabral integrity and glenoid depth in maintaining glenohumeral stability. Arthroscopic techniques to treat posterior instability are emerging. Until recently, reports of arthroscopic reconstruction focused entirely on capsular glenohumeral stability by altering two separate mechanisms: deepening of the glenoid concavity and reducing the capsular joint volume. This is accomplished by shifting the capsule to buttress the glenoid labrum. Thus increasing capsular tension increases the resultant compressive force vector into a deepened glenolabral concavity that, when combined together, enhances glenohumeral stability. In clinical and laboratory settings, we have shown that posteroinferior shoulder instability is associated with both capsular laxity and well-defined pathological lesions of the glenolabral concavity. Our results indicate that arthroscopic posterior capsulolabral repair and augmentation is a useful tool to restore the depth of the glenolabral concavity and to reduce the redundant posteroinferior capsule. This technique is effective in treating posteroinferior instability.     

Arthroscopic treatment of instability attributable to capsular injury or laxity

Among the many causes of shoulder instability are traumatic capsular injury associated with the Bankart lesion and capsular laxity as seen in multidirectional instability. Previously, open surgical procedures were the most commonly accepted surgical treatment of these disorders. However, because of the foresight of surgeons such as Richard Caspari, arthroscopy rapidly is becoming the surgical treatment of choice. Current studies have shown a 97% satisfactory outcome of arthroscopic Bankart repair. Similarly, the arthroscopic treatment of multidirectional instability has produced a 93% satisfactory outcome. These results parallel the gold standard open surgical techniques of the past and subsequently have led to a change in the treatment of shoulder instability.     

Outcome after failed traumatic anterior shoulder instability repair with and without surgical revision

The purpose of this study was to evaluate the incidence and reasons of recurrent instability in patients with traumatic anterior shoulder instability and to document the clinical results with regard to the number of stabilizing procedures. Twenty-four patients with failed primary open or arthroscopic anterior shoulder stabilization were followed for a mean of 68 (36-114) months. Following recurrence of shoulder instability, eight patients chose not to be operated on again, whereas 16 underwent repeat stabilization. A persistent or recurrent Bankart lesion was found in all 16 patients and concomitant capsular redundancy in 4. After the first revision surgery, further instability occurred in 8 patients, and 6 of them were stabilized a third time. Only 7 patients (29%) achieved a good or excellent result according to the Rowe score. All shoulder scores improved after revision stabilization. However, the number of stabilizing procedures adversely affected the outcome scores, as well as postoperative range of motion and patient satisfaction. Recurrent instability after a primary stabilization procedure represents a difficult diagnostic and surgical challenge, and careful attention should be paid to address persistent or recurrent Bankart lesions and concomitant capsular reduncancy. A satisfying functional outcome can be expected mainly in patients with one revision surgery. Further stabilization attempts are associated with poorer objective and subjective results.