Prospective evaluation of arthroscopic stabilization of acute, initial anterior shoulder dislocations in young athletes. Two- to five-year follow-up

From March 1992 to November 1998, 57 patients sustained 58 acute, initial, traumatic anterior shoulder dislocations at the United States Military Academy. Six patients selected nonoperative treatment. Three patients underwent primary open repair after diagnostic arthroscopy revealed no Bankart lesion amenable to repair with the bioabsorbable tissue tack. The remaining 48 patients with 49 anterior dislocations were treated with arthroscopic primary repair. There were 45 men and 3 women with an average age of 20 years (range, 17 to 23) and an average follow-up of 37 months (range, 24 to 60). The average Rowe score was 92 (range, 30 to 100). The average single assessment numeric evaluation patient rating was 95.5% (range, 50% to 100%). The average Short Form-36 score (physical function) for the stable shoulders was 99 (range, 95 to 100). Forty-three shoulders remained stable (88%). There were six failures (12%). Factors associated with failure included a history of bilateral shoulder instability, a 2+ sulcus sign, and poor capsulolabral tissue at the time of repair. All patients with stable shoulders returned to their preinjury levels of athletic activity. With follow-up of 5 years, we have observed significantly better results compared with nonoperative treatment in young, active adults at the United States Military Academy.     

The arrow versus horizontal suture in arthroscopic meniscus repair A prospective randomized study with arthroscopic evaluation

In a prospectively randomized study including 68 patients, the results of inside-out horizontal meniscus suturing were compared to meniscus repair using the meniscus arrow. 96% of the patients underwent re-arthroscopy after 3–4 months. Only lesions in the red/red or red/white areas were included. Patients were treated with a hinged brace for 9 weeks. 30 patients had an isolated bucket-handle lesion. In 19 cases the repair was done in conjunction with an ACL reconstruction and in 19 cases the repair was performed in an ACL-insufficient knee. The two groups were comparable. Operating time in the arrow group was one half that of the suture group. Of 65 re-arthroscopies, 91% of the patients had healed or partially healed in the arrow group compared to 75% in the suture group (P = 0.11). In only 50% of the non-healed cases was this clinically suspected prior to control arthroscopy. The difference between healing in ACL-reconstructed and ACL-insufficient knees was not significant. Two patients in the suture group had a deep infection. There were no serious neurovascular injuries. Five patients in the suture group and two patients in the arrow group had symptoms in the saphenous nerve area. All patients had some synovial irritation at control arthroscopy but no severe reactions to suture or arrows were seen. Short-term results with meniscus arrows, based on healing and evaluated by second-look arthroscopy, seem promising. Received: 20 May 1998 Accepted: 15 April 1999     

Comparison between metal and biodegradable suture anchors in the arthroscopic treatment of traumatic anterior shoulder instability: a prospective randomized study

Purpose  

The purpose of this study was to compare the clinical outcome of arthroscopic treatment of shoulder instability with metal and biodegradable suture anchors.     

A prospective, randomized clinical investigation of the treatment of first-time ankle sprains

BACKGROUND: Acute ankle ligament sprains are treated with the use of controlled mobilization with protection provided by external support (eg, functional treatment); however, there is little information regarding the best type of external support to use. HYPOTHESIS: There is no difference between elastic wrapping, bracing, bracing combined with elastic wrapping, and casting for treatment of acute, first-time ankle ligament sprains in terms of the time a patient requires to return to normal function. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Patients suffering their first ligament injury were stratified by the severity of the sprain (grades I, II, or III) and then randomized to undergo functional treatment with different types of external supports. The patients completed daily logs until they returned to normal function and were followed up at 6 months. RESULTS: Treatment of grade I sprains with the Air-Stirrup brace combined with an elastic wrap returned subjects to normal walking and stair climbing in half the time required for those treated with the Air-Stirrup brace alone and in half the time required for those treated with an elastic wrap alone. Treatment of grade II sprains with the Air-Stirrup brace combined with the elastic wrap allowed patients to return to normal walking and stair climbing in the shortest time interval. Treatment of grade III sprains with the Air-Stirrup brace or a walking cast for 10 days followed by bracing returned subjects to normal walking and stair climbing in the same time intervals. The 6-month follow-up of each sprain severity group revealed no difference between the treatments for frequency of reinjury, ankle motion, and function. CONCLUSION: Treatment of first-time grade I and II ankle ligament sprains with the Air-Stirrup brace combined with an elastic wrap provides earlier return to preinjury function compared to use of the Air-Stirrup brace alone, an elastic wrap alone, or a walking cast for 10 days.     

Arthroscopic evaluation of acute initial anterior shoulder dislocations

Arthroscopic evaluation of patients with an acute anterior shoulder dislocation was done to identify and classify the intraarticular lesions that might predict recurrent dislocations. Forty-five shoulders fit the following criteria for inclusion in our study: initial dislocation with no prior history of shoulder problems; confirmation of the dislocation radiographically or reduction by a physician; and arthroscopy within 10 days. The 42 men and 3 women had an average age of 21.2 years (range, 14 to 28 years). Mechanism of injury was a twisting of the arm into forced abduction and external rotation, a fall on the outstretched arm, or a direct blow to the shoulder. Based on this preliminary study of 45 shoulders, we present a classification of the lesions found in the acute shoulder dislocation. Group 1 (six shoulders) had capsular tears with no labral lesions: these shoulders were stable under anesthesia and had no or minimal hemarthrosis. Group 2 (11 shoulders) had capsular tears and partial labral detachments: these shoulders were mildly unstable and had mild to moderate hemarthrosis. Group 3 (28 shoulders) had capsular tears with labral detachments: these shoulders were grossly unstable and had large hemarthrosis. They had complete capsular/labral detachments. In the past, redislocation rates have been primarily related to age at the time of initial dislocation and, to a lesser degree, the period of immobilization. We have identified the intraarticular lesions in 45 patients with an initial anterior glenohumeral dislocation and classified these shoulders into three groups based on the lesions found. By doing so, we can develop a more accurate method of determining which shoulders are prone to recurrent dislocation.(ABSTRACT TRUNCATED AT 250 WORDS)     

A prospective controlled randomized study of arthroscopic lavage in acute primary anterior dislocation of the shoulder: One-year follow-up

Traumatic primary anterior shoulder dislocation has a very high recurrence rate among young people. This has supplied the motivation for studies to find methods of treatment that might become an alternative to traditional therapy. A prospective controlled study was performed to test the hypothesis that acute arthroscopic lavage might have a positive effect on recurrence rate as well as on shoulder stability, range of motion and mobilization, 30 consecutive patients between 18 and 30 years of age were randomized into 2 groups, I control group treated conservatively and 1 group treated with acute arthroscopic lavage within 10 days. Clinical examination was made by an independent observer at 1, 6 and 12 months. Results at 6- and 12-month check-ups showed a statistically significantly lower rate of redislocation and a wider range of motion for the group treated with acute arthroscopic lavage. Functional assessment according to the Lysholm shoulder score also indicated better functioning of the joint. Our 1-year follow-up shows very promising and interesting results.     

Anterior shoulder stabilization in collision athletes: arthroscopic versus open Bankart repair

BACKGROUND: Collision athletes are reported to be at high risk for redislocation after anterior stabilization of shoulder instability. Some authors have suggested that arthroscopic stabilization produces results similar to those of open stabilization. PURPOSE: To evaluate the results of anterior shoulder stabilization in collision athletes and to compare the clinical results between the arthroscopic and open methods. HYPOTHESIS: Open stabilization might produce better results than does arthroscopic stabilization in collision athletes. STUDY DESIGN: Cohort study; Level of evidence, 4. METHODS: Forty-eight shoulders of 46 collision athletes were enrolled for this study. The mean age of the patients at the time of surgery was 20 years, and the mean follow-up period was 72 months (range, 30-136 months). Sixteen shoulders underwent arthroscopic stabilization; 32 shoulders had open repairs. RESULTS: Visual analog scale, Rowe, and Constant scores improved after surgery, but no statistically significant difference was found between the arthroscopic and open repair groups. Thirty-seven athletes (83%) returned to near-preinjury sports activity levels (>/= 90% recovery) after operation. Two patients (4%) had subluxation and 6 (12.5%) had redislocation after surgery. The number of shoulders with postoperative subluxation or dislocation was 4 (25%) in the arthroscopic group and 4 (12.5%) in the open group (P = .041). Revision surgery was performed on 5 shoulders (10.4%). CONCLUSIONS: There were 8 (16.5%) instances of postoperative instability among the collision athletes studied. The arthroscopic group yielded a higher failure rate than did the open group. The authors believe open stabilization to be a more reliable method for anterior shoulder instability in collision athletes.     

Arthroscopic versus open shoulder stabilization for recurrent anterior instability: a prospective randomized clinical trial

BACKGROUND: Arthroscopic stabilization for anterior shoulder instability has been reported to result in a higher rate of recurrent instability compared to traditional open techniques. PURPOSE: To test the null hypothesis that there is no difference in the clinical outcomes in patients with recurrent anterior shoulder instability treated with open or arthroscopic stabilization. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A consecutive series of 64 patients with recurrent anterior shoulder instability were randomized to receive either arthroscopic or open stabilization by a single surgeon. Magnetic resonance arthrogram studies were obtained preoperatively. These findings were compared to arthroscopic findings. Postoperative evaluations included range of motion, stability, and subjective assessments including Single Assessment Numeric Evaluation, Simple Shoulder Test, Western Ontario Instability Index, and University of California, Los Angeles evaluation. Failure was defined as a second dislocation, recurrent subluxation, or symptoms precluding return to previous work or unrestricted active military duty. RESULTS: Sixty-one patients, 29 who received open stabilization and 32 who received arthroscopic stabilization, were evaluated at a mean of 32 months postoperatively (range, 24-48 months). Patient demographics were equivalent. Preoperative magnetic resonance arthrogram findings were confirmed at arthroscopic examination. The mean operative time was significantly shorter for the arthroscopic repairs (59 vs 149 minutes; P < .001). There were 3 clinical failures (2 open stabilizations, 1 arthroscopic stabilization) by the established criteria. There was a statistically significant improvement from preoperative to postoperative Single Assessment Numeric Evaluation scores in both groups (P < .001). The mean loss of motion (compared to the contralateral shoulder) was greater in the open shoulders. Subjective evaluations were equal in both groups. Conclusion: Clinical outcomes after arthroscopic and open stabilization were comparable. Preoperative magnetic resonance arthrograms in shoulders with anterior instability allow an accurate diagnosis of intra-articular abnormality that correlates well with operative findings. Arthroscopic stabilization for recurrent anterior shoulder instability can be performed safely; the clinical outcomes are comparable to those after traditional open stabilization.     

Early arthroscopic treatment of primary traumatic anterior shoulder dislocation. A follow-up study

This study evaluates the results of early arthroscopic Bankart repair in patients with primary traumatic anterior dislocation of the shoulder. The patients'age range was 17–34 years. Arthroscopic Bankart repair was performed within 12 days after the dislocation. First follow-up was at 18 months. According to Rowe's score, 11 patients (73%) were excellent, 3 (20%) were good and 1 (7%) was poor. The median external rotation deficit was 4 in the adducted position. At a second follow-up at 34 months, two patients had redislocated. Both of these patients had severe generalized joint laxity. Another patient reported frequent subluxations. We conclude that in young patients with primary anterior traumatic shoulder dislocation, early arthroscopic Bankart repair implies a low recurrence rate and restores shoulder function to normal. Generalized joint laxity could indicate an increased risk for recurrent dislocation.     

The effect of early arthroscopic stabilization compared to nonsurgical treatment on proprioception after primary traumatic anterior dislocation of the shoulder

This randomized clinical trial compared the effect of early arthroscopic stabilization and rehabilitation vs. standard immobilization and rehabilitation on measures of shoulder proprioception. Subjects with primary traumatic anterior dislocations of the shoulder were randomized into one of two groups: standard therapy of immobilization and rehabilitation (n=13) or arthroscopic stabilization followed by rehabilitation (n=11). At a minimum of 3 months posttreatment (mean 19 months) proprioception was evaluated using threshold to detection of passive motion (TTDPM) and reproduction of passive positioning (RPP) at 30 degrees and 60 degrees external rotation. There were no statistically significant differences between surgical and standard treatment groups in either TTDPM or RPP at start positions of 30 degrees and 60 degrees. These findings suggest that treatment by early arthroscopic stabilization and rehabilitation after primary traumatic anterior dislocation of the shoulder does not enhance proprioception more than standard immobilization and rehabilitation.     

A prospective cohort study investigating the effect of generalized joint hypermobility on outcomes after arthroscopic anterior shoulder stabilization

Objectives: Generalized joint laxity has been proposed as a significant risk factor for failure after arthroscopic anterior shoulder stabilization. The purpose of this study was to prospectively measure joint mobility in patients undergoing arthroscopic anterior shoulder stabilization and to determine whether hypermobility is a risk factor for worse outcomes compared with patients having normal joint mobility.

Methods: Patients with anterior shoulder instability were prospectively enrolled. Generalized joint hypermobility was measured using the Beighton Hypermobility Score and the Rowe, UCLA, SANE, SST, and WOSI scores were administered and reported as patient outcomes preoperatively and following arthroscopic anterior shoulder stabilization at 6 weeks, 6 months, 12 months, and 24 months postoperatively. Patients were stratified into two groups based on their Beighton Hypermobility Score, with scores ≥ 4/9 indicative of joint hypermobility.

Results: Sixteen patients with joint hypermobility (JH) and 18 non-hypermobile patients (NJH) were enrolled. At baseline, there were no significant differences in demographic characteristics or baseline patient-reported outcomes. Significantly more patients in the NJH group had SLAP tears (n = 10) compared to the JH group (n = 2) (p = .013). At all follow-up times, there were no significant differences between the NJH and JH groups with regard to patient-reported outcome scores (p > .05). In the JH group, 17% of patients reported recurrent instability at two years postoperatively compared to 25% of patients in the NJH group. There was no significant difference in failure rate (p = .67).

Conclusion: There was no significant difference in patient-reported outcomes or recurrent instability in patients with versus without joint hypermobility undergoing arthroscopic anterior shoulder stabilization.     

Comparison of open and arthroscopic stabilization for recurrent shoulder dislocation in patients with a Bankart lesion

We performed a prospective study of 117 patients (119 shoulders) with symptomatic, recurrent anterior posttraumatic shoulder instability to compare open versus arthroscopic reconstruction. Arthroscopic reconstructions (N = 66) were performed using bioabsorbable tacks (Suretac fixators), whereas open reconstructions (N = 53) were performed with suture anchors. All of the patients had a Bankart lesion. Independent observers examined 108 of the 119 shoulders (91%) at a median follow-up period of 28 months (range, 24 to 63) for the arthroscopic group and 36 months (range, 24 to 63) for the open group. The recurrence rate, including both dislocations and subluxations, was 9 of 60 (15%) in the arthroscopic group, compared with 5 of 48 (10%) in the open group. At follow-up, the Rowe score was 93 points (range, 39 to 100) and the Constant score was 91 points (range, 56 to 100) in the arthroscopic group, compared with 89 points (range, 53 to 100 and 57 to 100 for the Rowe and Constant scores, respectively) for both scores in the open group. The only significant difference was in external rotation in abduction, which was 90 degrees (range, 50 degrees to 135 degrees) in the arthroscopic group and 80 degrees (range, 25 degrees to 115 degrees) in the open group. Both methods produced stable and well-functioning shoulders in the majority of patients.     

Comparison of surgical repair or reconstruction of the cruciate ligaments versus nonsurgical treatment in patients with traumatic knee dislocations

BACKGROUND: Studies of traumatic knee dislocations have failed to provide a consensus regarding the best method of treatment. PURPOSE: Our purpose was to evaluate the results after surgical repair or reconstruction versus nonsurgical treatment and to compare the influence of prognostic factors. STUDY DESIGN: Retrospective study. METHODS: Eighty-nine patients were treated for traumatic knee dislocation. Surgical repair or reconstruction of the cruciate ligaments was performed in 63 patients (repair, 49; reconstruction, 14). In 26 patients, nonsurgical treatment was undertaken. RESULTS: At an average follow-up of 8.2 years, the mean Lysholm and Tegner scores were 75 and 3.7, respectively. The outcome in the surgical group was better than in the nonsurgical group. The scores were higher in patients who were 40 years of age or younger, who had sports injuries rather than motor vehicle accident injuries, and who had undergone functional rehabilitation rather than immobilization. CONCLUSIONS: Surgical repair or reconstruction of the cruciate ligaments was superior to nonsurgical treatment. Functional rehabilitation was the most important positive prognostic factor. Surgical repair or reconstruction of the cruciate ligaments is mandatory to achieve sufficient stability for functional rehabilitation. In cases of cruciate ligament avulsion, repair with transosseous fixation is a reasonable alternative to reconstruction, provided that it is performed within 2 weeks of trauma.     

Postarthroscopy analgesia with bupivacaine. A prospective, randomized, blinded evaluation

The analgesic effect of intraarticular bupivacaine injected at the conclusion of knee arthroscopy done under general anesthesia was investigated in a prospective, randomized, and blinded fashion. Pain scores, the use of analgesic medications, crutch use, weight-bearing, activity level, and difficulty sleeping the night after surgery were all unaffected by the use of bupivacaine. The apparent lack of effect is most likely due to rapid clearance from the knee, leaving only a transient, 1 to 2 hours of potential benefit. In this study, the patients were already quite comfortable during this time period due to the routine use of intraoperative narcotics. The preoperative level of knee discomfort was found to be a major determinant of postoperative discomfort. Other much less important factors were synovial and chondral shaving, sex of the patient, and experience of the surgeon.     

The diagnosis and nonoperative treatment of shoulder injuries in athletes

The specific emphasis in this article has been directed toward the diagnosis of prevalent shoulder pathology in a young athletic population; however, as the interest in sports has blossomed in recent years now encompassing a larger age range, the physician must not neglect common pathologic conditions of the older athletes. Fastidious adherence to complete history, physical examination, and a high level of suspicion for uncommon disorders is paramount. Arthritides such as osteo, rheumatoid, septic, and lyme as well as the hematologic disorders of multiple myeloma, lymphomas, leukemia, hemophilia, and Gaucher's disease can all present with shoulder pain. Thoracic outlet syndrome, scalene syndrome, supra-scapular nerve syndrome, and quadrilateral space syndrome comprise a group of nerve compression syndromes that are becoming more apparent as our diagnostic skills improve. Yet, the most pervasive disorders in the young athlete are due to lack of shoulder stability. By understanding the delicate balance in normal shoulder between mobility and stability, the clinician is better able to conceptualize the etiology and progression of the problem, and design the optimal treatment program.     

Comparison of shoulder stabilization using arthroscopic transglenoid sutures versus open capsulolabral repairs: a 5-year minimum follow-up

BACKGROUND: Few long-term studies have compared the efficacy of shoulder stabilization using arthroscopic or open procedures. PURPOSE: To directly compare the outcomes of shoulder stabilization using arthroscopic transglenoid sutures versus open capsulolabral repairs. STUDY DESIGN: Uncontrolled retrospective review. METHODS: Fifty patients (30 arthroscopic and 20 open) were followed for a minimum of 5 years (mean, 68 months). Pain, motion, strength, function, stability, patient satisfaction, radiographs, and ability to return to preinjury activity levels were evaluated. RESULTS: The arthroscopic group had a 17% (5 of 30) dislocation rate and a 60% (18 of 30) rate of instability. Sixty-seven percent (6 of 9) of patients participating in collision sports had repeat instability. Eight of 18 patients with instability required open repair for persistent symptoms. There were no limitations of motion following arthroscopic stabilization. The open group had no episodes of dislocations or instability. Forty-five percent (9 of 20) had some loss of external rotation (range, 10 degrees -40 degrees ) with a mean loss of 18. The one failure in this group had a 40 degrees loss of external rotation and difficulty with recreational activity. No patients participating in collision sports had repeat instability. CONCLUSION: We recommend open stabilization for patients participating in collision sports (for example, football, wrestling) or activities where better stability is required. For those participating in sports where performance may be compromised by loss of external rotation (such as swimming), newer arthroscopic techniques are recommended.