Arthroscopic vs. Open Anterior Shoulder Stabilization
abstract & commentary
Synopsis: In properly selected patients, results of arthroscopic shoulder stabilization are similar to an open capsular shift procedure.
Source: Cole BJ, et al. Comparison of arthroscopic and open anterior shoulder stabilization. A two- to six-year follow-up study. J Bone Joint Surg Am 2000;82-A:1108-1114.
The debate continues regarding whether results of arthroscopic stabilization of anterior shoulder instability are comparable to traditional open procedures. High recurrence rates have been reported for some arthroscopic procedures; however, as the present paper elucidates, this may have been related to proper patient selection, rather than the procedure per se. The paper presents two-to six-year follow-up results of 59 patients with traumatic anterior instability treated with either an arthroscopic (Suretac) or open capsular shift procedure. The groups were not randomized—patients with inferior instability, capsular laxity, capsular rupture, or capsular tissue without discrete ligaments were treated with an open capsular shift procedure. Patients who did not have significant inferior instability and had a discrete Bankart lesion and well-formed glenohumeral ligaments were selected for an arthroscopic Bankart repair.
Thirty-seven patients underwent an arthroscopic procedure, and 22 patients had an open capsular shift. Cole and associates were able to locate and evaluate 94% of the patients in the original study group (59/63 patients). The treatment groups did not differ with regard to age, hand dominance, mechanism of initial injury, duration of follow-up, or time until surgery. The results of the two groups were not statistically different with regards to failures or outcome as measured by both the Rowe and ASES scoring systems. Cole et al conclude that 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.
COMMENT by Mark Miller, MD
This paper provides additional support for advocates of arthroscopic shoulder stabilization. However, as Cole et al clearly indicate, there are as many as one-third of patients who are not suitable candidates for arthroscopic repair. Therefore, surgeons must still be familiar with open procedures and know when to abandon arthroscopic techniques in favor of open repair. It is also important to note that all arthroscopic procedures were done with an absorbable tack. Many surgeons (including Cole et al) have largely abandoned this in favor of suture anchors. As newer techniques continue to be introduced, it is critical that surgeons stay current while recognizing that different results (good or bad) may be associated with these newer devices. Perhaps the biggest flaw of this paper is with patient selection. Cole et al are comparing the results of their arthroscopic techniques done in patients with the best pathoanatomy (for either type of repair) with results of open procedures done in patients with more laxity and worse tissue. Although they do make a good point regarding the importance of patient selection for arthroscopic techniques, perhaps these should be compared to the results of open procedures done in patients with similar pathoanatomy rather than the "arthroscopic rejects.
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