cr Open Versus Arthroscopic Stabilization for Traumatic Anterior Shoulder Instability Richard K. N. Ryu, MD ‘Summary: Symptomatic, ecurent anterior shoulder instability ro- quires stbilization, open or arthroscopic. The arthroscopic approcch thas im th past, been associated with a worrisome recurrence rate, By adhering o strct clinical end technical eitera including restoration Of the proper resting length ofthe glenobumerel ligament as wel as recreation ofthe labral "bumper," curent arthroscopic techniques can coffer sucess rates comparable to those reported with open tech- niques. Key Words: anterior instbilty, shoulder dislocation, Bankactrepir, Inbral tear (Sports Med Arthrose Rey 2004;12:90-98) Tris it dont tit hoe suing tom rere n- terior shoulder instability benefit greatly from stabilization procedures. Historically, open stabilization surgery has ‘yielded satisfactory results with recurrence rates usually under 10% andas low as 2%." Unfortunately these same open pro- ccodures have been associated withnumerous complications in- cluding late chondrolysis,* significant motion restriction,?* hardware loosening and breakage, an arduous rehabilitation, and cosmetically disppointing incisions. ‘The application of arthroscopic techniques in the man- ‘agement of anterior instability has been used for nearly 2 de- cades, andthe inital reasons remain compelling: (1) postop- trative motion gains that re critical to the overband athlete, (2) facilitated (although not shorter) rehabilitation, (3) an op- portunity to completely evaluate and treat associated intra- articular pathology, (4) shortec operative time and potentially lower costs, and (5) enhanced cosmetic outcomes. However carly optimism has been tempered with the historically lower success mates reported with the procedure, sometimes ap- proaching 50% in skilled and experienced hands. This current dilemma begs the obvious question: “When confronted with recurrent, traumatic, anterior instability, should the procedure of choice be an open procedure or is ax- thro scopic stabilizationthe preferred solution?” Thisarticleat- Privat atc, Senta Berber, Califia ‘Reprints: Dr. Richard KN. Ry, S33 E. Micheltorena Sant Babar, CA. ‘9340 (om famryus@uo cara). (Copyright © 2004 by ppc Wiliams & Wilkins 90 tempts to answer this question by reviewing the pertinent pathoanatomy, the available clinical data, and the surgical techniques associated with a successful outcome. Recommen- dations, based on pathoanatomy and known risk factors, for both open and arthroscopic techniques are presented. When discussing stabilization surgery, itis critical to remember that the guidelines espoused in this article are specifically forthose patients suffering from recurrent traumatic, anterior shoulder - PATHOANATOMY ‘When discussing shoulder instability, several pertinent anitomio and biomechanical issues deserve ercphasis, Lsta- bility is pathologic condition ofthe capsuloligamentouscom- plex whereas laxity is a physical finding. Physiologic laxity ‘ean become symptomatic overtime and could, at that time, be considered “pathologic”, Studies by Turkel"® and O'Brien, in solective cutting studies, have determined that with the shoulder in 90° of abduction, the anterior-inferior glenohu- ‘eral ligament remains the primary static restraint to anterior ‘wanslation. Additionally, intrinsic shoulder stability depends ‘on an intact inferior glenohumeral ligament-labral complex that deepens the glenoid and also provides “bumper” effect ‘the glenoid rim.' Detachment of the labrum can decrease socket depth by nearly 50% whereas the resistance to transla- tion can also be diminished by 20%." Negative intra-aticular pressure (the “suction effect’) can contribute to joint stability. ‘The concavity-compression effect isa critical one and relies on an intact labrum and a well-functioning rotator cuff. Dy- samc stabilizers ofthe shoulder inchude the biceps'” as well as the lager extrinsic shoulder musculature, which in combine- tion with static stabilizers provides and maintains shoulder sta- bility. Version of the glenoid can also 6e considered a static stabilizer in that variations of glenoid version can predispose to instability patters.® Shoulder instability can arise if any or a combination of these forces is disrupted or is abnormal. Sectioning and stress testing have also demonstrated that although considered the “essential” lesion, a Bankart lesion alone is not enough to pecmit recurrent instability. "™29 Asso. ciated plastic deformation of the glenohumeral ligaments isa necessary factor in recurrent instability and must be ad- Sports Med Arthrosc Rev * Volume 12, Number 2, June 2004Sports Med Arthrosc Rev « Volume 12, Number 2, june 2004 dressed ifsuccessfil stabilization isto be achieved arthroscop- ically. Although the rotator interval bas historically been impli- cated in the spectrum of pathologie changes associated with ‘multidirectional instability,”"~® the rotator interval may also Contribute to recurrent, anterior shoulder instability. A persis- tent preoperative sulcus sign with the shoulder in adduction ‘and external tation should rise concem regarding te integ- rity of the rotator interval. Intr-operative findings of a patu- lous interval, ballooning out with increased intra-articular pressure, often in association with poorly defined glenohumer- a ligaments should be recognized and must be considered in the treatment plan* LITERATURE REVIEW Arthroscopic Stabilization With the advent of arthroscopy, and with the rapid tech- nical advances and improved implant choices, arthroscopic stabilization quickly became the “panacea” for traumatic shoulder instability. Barly reports were encouraging, >“ ci. {ng the many advantages ofthe arthmoscopie approach, includ- ing minimal surgical trauma, a facilitated rehabilitation with ‘uch less peri-operative morbidity in addition to the ability to recognize and treat associated pathology while sparing the subscapilaris, and providing fora desirable cosmetic outcome. ‘However with longer-term follow-up, the inital sue. cess rates plummeted with recurrence rates approaching 50%. Several risk factors were determined tobe statisti- cally significant for recurrent instability following arthro- scopic dabilization. A short period of postoperative immobi lization’? bony, Bankart lesions leading to “inverted pear” configurations®*? associated generalized ligamentous lax- ity", targe and Hill-Sachs lesions,"** contact orcollision sports, “#224312 the younger patient, as well 4s poor glenobumeral ligament quaity”"™*"2? have all been {mpliceted as tisk factors for arthroscopic failure, Although many cogent and timely articles focusing on the results of arthroscopic stabilization have been published, there area few that merit closer attention. In 1993 Grana™ was ‘one ofthe first investigators to documenta recurrent instability ‘ate of nearly 45% in trensplenoid Bankart repairs. An analysis of isk factors revealed a short immobilization period as a sta- tistically significant risk factor while age, dislocation over sub- luxation, and contact sports trended toward significance Walch in 1995 reported a failure rte of nearly 50% in his transglenoid Bankart repair series, and noted that associated ligamentous laxity andthe presence of a bony Bankai injury were 2 statistically significant isk factors for recurrent insta- bility fellowing arthroscopic stabilization. Pagnani etal in 1997 reported a 19% failure rate in a series of 102 patients followed for over2 years Transglenoid stabilization was used in appreximately 50% ofthe patients while the remaining pa- © 2008 Lippincom Miliams & Wilkins Oven Versus Arthroscopic Stabization tients were stabilized witha bio-tack technique. They identi- fied 4 vik factors, mamely generalized ligamentous laxity, poorly defined glenchameral ligament, the absence of a Ban ‘art lesion, and participation in a contact sport, They con cluded that these risk factors were also additive and that those ‘with3 of the risk factors ad the highest recurrence rate of 43% compared with those without risk factors whose recurrence ‘ate was only 32, Torchia et a!™ in 1997, using multivariate snalysis with a single surgeon and consecutive patients, deter- ‘ined thatthe preseace ofa Bankart lesion anda younger age, Were 2 of the mos significant risk factor for fuiled transgle. noid stabilization. Burkhart and DeBeer™ introduced the con- cepts of the glenoid “inverted pear” configuration as well as the “engaging HillSachs lesion,” both bony defects contiib- ‘ted toa failure rate approaching 70% in their series. Itisnote- ‘worthy that in their patient population without significantbone loss, the recurrence rte was only 4%, In contrast to these studies, there have been recent re- Ports of greater sucess rte following arthroscopic interven- tion. Bacilla and Savoie in 1997, utilizing suture anchors and ‘nonabsorbable suture, reported a failure rate of only 9% de- spite treating 40 consecutive young, high-demand athletes, 38 of whom were younger than 22 years of age. They concluded that there were no specific risk factors that could be identified orthat were associated witha higher recurrence rate, O'Neil?” in 1999 cited a recumence rate of only 5% after treating high- demand athletes with a transglenoid stabilization for anterior instability. 40 of 41 patients returned to their previous level of competition with follow-up averaging over 4 years. Twenty. two of the 41 patents regained a fll range of motion, and 2 patients reported @ single subluxation episode post- operatively. Romeo," reporting on a consecutive seies of 30 Patients treated with arthroscopic stabilization using a “S- o'clock” portal, experienced no recurrences with a minimum, ‘year follow-up. Gartsman’” in 2000 cited a success rate of 92.5% inthe arthroscopic stabilization of chronic anterior in- stability using suture anchors and non-absorbable suture, Ad- Junetive capsular plication and closure of the rotator interval ‘was implemented in conjunction with repair of the Bankart lesion. Mishra et lin 2001 reported a failure rate of only 7% with greater than 2-year follow up ina group of patients treated with a Bankart repair and adjunctive thermal capsulorshaphy, The thenmal treatment was implemented as a means of short. ening the glenobumiera ligaments in conjunction with a Ban kart repair. Thirty-eight of 42 patients retuned to their prior level of sports paticipation, 14 of whom were contact or col- lisionatletes. Using not only dislocation and subluxation, but also positive apprehension as criteria for failure, Kim et alin 2008 cited a 4.2% recurrence rate ia 167 patients following axttroscopic stabilization with a 2- to 6-year followup. These results ae very similar tothe 3.4% recurrence rate previously Published by Kim in a prospective study comparing open and 1au arthroscopic results. [tis noteworhy that only 1 patient out of the 167 in his study actually sustained a recurrent disloca- tion whereas 4 described apprebension. Prospective Studies ‘Although results fom prospective studies have been re~ ported, zone fally adhere to the randomized, blinded format that delivers the most reliable data. In 1991, Weber," ina non- randomized study, described a failure rate of 16% for arthro- scopic repairs versus 4% in the open group. As expected, the overhand athletes in his study exhibited a 3-fold greater like- tihood of returning to their pre-morbd level of competition. Guanche? in 1996 revealed a failure rte of 33% compared ‘with 8% in the open group. Mean follow-up averaged over 2 years for both groups although the overall sample size was ‘smal. Geiger’ described a 43% failure rate with arthroscopic stabiliztion compared with 0% in the open stabilization co- hr, both groups part ofa non-randomized prospective study. re also concluded thatthe range of motion was not improved in the arthroscopic treatment group. Field in 1999 cited 0% recurrence rate utilizing an open technique in his prospective study whereas those treated with an arthroscopic stabilization exhibited a respectable 8% recurrence rete. Cole™ in 2000 in- cluded apprehension as well as subluxation and frank disloce- tion this study eriteria comparing open and arthroscopic ech- ‘niques and reported recurrence rates of 24% inthe arthroscopic group compared with 18% inthe open category, statistics note- ‘worthy not so much for the higher rte in the arthroscopic group, but for the unexpected failure rate of 18% in those treated with an open stabilization, Sperber in 2001" also re- ‘ported on his short-term results comparing open and arthro- scopictochniques and although the arthroscopic technique was associated with a failure rate of 23%, the open technique was associated with a failure rate of 12%, again considerably higher than the traditional 3% to 4% recurrence rate histor cally associated with open techniques. Kim et ain the most compelling prospective study, using stringent criteria, deter- ‘mined that there was no significant difference in outcome be- ‘ween the 2 groups with regard to recurrent instability rates. If apprehension is inchaded asa criterion for failure, then arecur- rence rte of 10% and 10.2% is reported for the open and a throscopic groups respectively. In assessing recurent disloca- tions, his open group fared worse with an incidence of 6.7% compared with 3.4% in those treated arthroscupically. ANALYSIS OF FAILED ARTHROSCOPIC STABILIZATION Because of the higher failure rate associated with athro- scopic stabilization procedures, opportunities to study possible causes are abundant. Mologne evaluated 20 paticats who de- veloped recurrent anterior instability after arthroscopy. His analysis revealed healed Bankar lesions in 60% whereas 40% (B patients) demonstrated recurrent Bankart lesions. Fifteen 92. Sports Med Arthrosc Rev * Volume 12, Number 2, june 2004 (13%) ofthe failures were noted to have capsular redundancy, an he concluded tet recurrent Bankart lesions were an obvi- ous source of failure, but that untreated or unrecognized cap- sular deformation was aso a common cause for failure follow- ing an arthroscopic Bankart repair. Speer‘? and Wemer** acted a high incidence of capsular laity with intact Bankert repairs in their filed cases, again emphasizing the importance of capsular treatment in conjunction with the Bankart repair. Wolf’ reported on 8 failures evaluated arthroscopically, and be noted that 2 post-surgery dislocations caused by major trauma were distinguished by recurent Bankert pathology ‘whereas the remaining 6 failures were all noted to exhibit cap- sular insufficiency. Kim detailed his experience in arthro- scopically revising failed Bankart procedures, both open and arthroscopic. He determined that although risk fctors such as bone loss and contact sports remained relevant, tchnical er- rors were commonly encountered. Medialization and non- smatomic repair of the Bankart lesion, essentially creating an ALPSA (anterior labroligamentous periosteal sleeve avulsion) lesion," accounted for several failures. Poor anchor placement and poor tensioning of the glenohumeral ligaments likewise contributed to a high recurrence rate. Interestingly, Torchia et al in1997 cited a failure rate of 16% in his translenoid sta- bilzation series, In addition to a younger age, presence of a Bankart lesion was considered a statistically significent visk factor for recucrence. This factor seems counter-intuitive, yet a cogent explanation followed. With the primary goal of repair- {ng the Banknrt lesion, the unrecognized capsular deformation ‘was not addressed as a surgical gol. By believing thatthe op- eration was simply one of restoring the labrum to its position oft the glénoid, the need to adequately teat the associated cap- sular lengthening was under-apprecisted, loading to the high failure rate in those with treatable Bankart injuries. OPEN STABILIZATION Rowe's! classic article from 1978 forms the basis forthe 3.5% failure rate often cited when discussing the metits of ‘open surgery. It is noteworthy that nearly 20% had non- ‘Bankart pathology and thatthe activity level following surgery ‘was pot well documented. Gill etal? reported on their long term results following open Bankart reconstruction with fol- low-up averaging over years. Instability recurred in 3 of 60 patients whereas 93% were feltto bave excellent or good out- comes. It should be noted tha the average mation loss in ex- ‘ternal rotation was 12°. Kiss et al* reported oni their long-term results with the PuttiPlatt procedure. An acceptable redislo- cation rate of 9% was cited with an average follow-up of 9 years. OF considerable interest were the findings that 11% of patients hed pein at rest while 35% described pain with activi ties. The average external rotation loss was 23°. Late arthritic change was moderate in 29% of the patient population and se- vere in 1%. Yoneda et al® in 1999 addressed the issue of open stabilization in the contact athlete, Eighty-three contact ath- © 2004 Lippincott Wiliams & WithinsSports Med Arthrose Rev * Volume 12, Number 2, June 2004 letes averaging 21 years of age were treated with » combined Bankart and coraccid transfer procedure. With an average fol~ low-up of nearly 6 years, 8% returned to their contact sport while average external rotation loss with the elbow atthe side was 15°, Pegnanj??in2002 authored what might be considered the definitive article on anterior stabilization for reeurest rau ‘atic instability inthe American football player. His study Population averaged 18.2 years of age, and the procedure coor sisted of an open Bankart repair supplemented by a capsular shift with the shoulder positioned in 45° of abduction and ex ternal rotation, Fifty-two of58 patients returned to competitive football. Two patients sustained a reeurreat subluxation for a failure rate of 3.4%. Eighty-four percent of the study group achieved arange of motion within 5° ofthe contralate side. Recent data suggests that the long-term follow-up of open stabilization surgery my reveal recuence ates that ap- proximate th failure rate reported in the most curentarthro- scopic Literature. Uhorchak in 2000," detailing a military academy experience, reported a re-dislocation rate of 3%, a Fecurrent subluxation rate of 19% fora combined 22% fulure ‘ate, All pstents wer collision or contac athletes, averaging 19.5 years in age with follow-up averaging 4 years. Magnus son in2002* evalusted 7 of54 open Bankats with follow-up exceeding 5 year. Sixty-tix percent ofthese individuals were contact or overhead athletes. The combined recurrent disloca. tion or subluxation rato was 17%, neazly 500% increase over the original results reported by Rowe. ‘The data gamered fom review ofthe literature i note- Worthy for differing patient populations, varying surgical tech. ‘niques, and results that at best would be considered “conflict- ing”. Are we witnessing the maturation ofa “technique in evo. lution”, namely arthroscupic Bankart repair, and are the recent ‘eports citing single digitrecurrence rates an indication of wat We cannow expect from ths intervention? Furthermore are we also witnessing a higher recutence rate associated with open Procedures asa result of longer-term follow-up? ‘With the identification of risk factors such as significant bone loss, contact sports, associated generalized ligamentous laxity, an the younger patient, the indications for arthroscopic stabilization for traumatic anterior instability have been re- fined and willbe reflected in higher success rates as the higher tisk patients are treated with alternative solutions, ‘The recent improvement in success rates also reflect the technical lessons that arthroscopic surgeons have discovered over the past decade regarding shoulder stabilization: 1. The damaged glenchuneral ligament must be sufficiently ‘mobilized so that an inferior to superior shift can be sccomn- plished and the capsule properly tensioned. 2. Placement of suture anchors must be on the glenoid face such thata labral “chock-block” is re-established versus an- chor placement on the glenoid neck (medialization), 3. At least3 suture anchors must be used inthe repair. © 2004 Lippincon Wiliams & Wilkins Open Versus Arthroscopic Stablization 4. Associated ligamentous laxity must be addressed in the form of capsular “tuck”, possible adjunctive thermal reat. ‘ment, andlor rotator interval closure, 5. Postoperative rehabilitation should be well supervised and individualized, especially if thermal energy is used con- comitantly. A minimum period of 3 to 4 weeks of restricted ‘motion should be implemented. ‘There may be an answer as to why the recurrence rates {for open and atroscopio sabilization seemto be converging, In addition to refinements in selection and improved surgical technique, pragmatic considerations such as the desire to in ‘rove postoperative external rotation, especially in the thow. ing athlete while performing an open procedure, may explain the convergence, Although an increase in external rotation be. comes one of the primaty surgical goals, the recurrence rate will surely increase with the open techniques because the shoulder can be placed in a more functional, but precarious position. Surgical Technique for Arthroscopic Stabilization ‘The principles guiding stabilization surgery, whether pen or arthroscopic, must be adhered to ifa satisfying out. come isto be obtained. The sequence of these essential tes is outlined below: 1. Lateral decubitus or beach chair positioning with the abil- ity to apply dual traction. Examination under anesthesia Should confirm the preoperative diagnosis. Comparison ‘With the contralateral side is recommended ifthe diagno. sis isin doubt 2 A dual anterior portal technique is recommended. A low ‘anterior portal just above the intra-articular sip ofthe ub. Scapularis is created as well as a high anterior portal di. rectly behind the biceps tendon, to facilitate anterior visu. alization Fg. 1). Although viewing fiom a posterior portal ‘with a70° lens isan alternative, viewing from an anterior- Superior portal provides the definitive view of labrl pa- thology andthe subsequent repair. The posterior portal is converted toa working poral to facilitate suture handing, 4. Once the joint is entered, ll pathology is carefully oval, ated, Associated rotator cuf or SLAP injusies may require Bankartlesion Fig 2) should be asessed including tissue integrity, presence of a bony component as well a5 sis. pected capsular redundancy, 4. This step isthe most critical one. The Bankart lesion must be completely freed from the neck ofthe glenoid. For the anterior ligamentous periosteal sleeve avulsion (ALPSA) lesion, this dissection canbe tedious. Bvery attempt should be made to avoid thinning the glenohumeral ligament due ing the dissection, At the completion of this step, the sub. 93FIGURE 1. The orientation is that ofthe lateral decubitus po- sition. The small arow points to the anteior-supeor viewing, cannula, entering directly behind the biceps. The larger arow indicates the low anterior working portal just superior to the intra-articular slip of the subscapulats tendon, scapularis muscle should be clearly visible through the tear site (Fig. 3). Grasping tools can be used to evaluate ‘how far the tissue can be shifted superiorly. 5. The anterior glenoid rim and neck are prepared with ring “Curette and a shaver. Use ofa motorized burr israrely neo- vestary, and may actually compromise bony purchase ot exacerbate bone los, 6. Through the low anterior portal, instrumentation for an- chor placement is placed st the lowest anchor sto first, 'pproximately the 7:00-o' clock position in «left shoulder The drill hole is made with the guide onthe glenoid face ‘by 2 or 3 mm (Fig. 4). This is essential for re-creating the FIGURE 2. In a Jefe shoulder, viewing from the anterior superior portal, the Bankart lesion remains scarred to the ary terior glenoid (arrows). A thorough dissection is needed to shift WSsue superior, 94 Sports Med Arthrose Rev » Volume 12, Number 2, june 2004 FIGURE 3. Once the inferior glenchumeral Igament (CHL) has been released, the subscapularis tendon is easly visualized, lubral bumper, but also ensures that the most inferior an- chor will achiove adequate bony purchase, 7. The suture anchor is inserted and the sutures separated, One strand is brought through the posterior cannula. A suture hook device is then loaded with O PDS and with the fm internally rotated while in dual traction, the inferior ‘lenoluinera ligament is penetrated approximately | to2 ‘minferior and lateral tothe suture anchor. Ths allows for adequate tissue shifting both lateral to medial and infor tp superior. A pinch-tuck maneuver (Fig. 5) ean also be 8 The 0 PDS suture is grasped through the posterior portal, sa the suture stand fom the aachor is broug hough FIGURE 4, The Initial anchor placement is the mast inferior one and should remain 2 or 3 mm cn the glenoid face (arrow), This permits adequate bony purchase and also allows ro: creation of a labral “bumper. ©2004 Lippincott Witams & WilkinsSports Med Arthrosc Rev » Volume 12, Number 2, june 2004 FIGURE 5, As seen from the anterior superior portal, the “pinch-tuck* technique allows addtional capsular shifting thereby reducing capsular volume, Arrows point to the "fold ing” of the “pinch-tuck" technique whereas the larger arrow depicts the sulcus created by “folding” a portion of the eaprule into the anchor stitch, simple loop in the PDS and thea retrograded through the labrum and retrieved from the low anterior portal (Fig. 6). ‘Separating sutures before this mancuver prevents twisting of the sutures as they exit the same cannula, 9. When tying knots, the suture limb retrograded through the labrum must remain as the post. Whether tying sliding knots or alternating half-itches, this sequence pushes the labrum onto the glenoid face (Fig. 7) re-creating the labral “bumper”. IFreversed, the knot pushes the labrum off the slenoid face. Knot-tying skills should be mastered before attempting this technique. Furthermore knot security and FIGURE 6. Curved arrow points to anchor placed on the glen- ld face. Straight arrow depicts “poor mats shuttle” in which (© PDS suture is used to retrograde a suture limb through the Inferior glenchumeral ligament (GHL} © 2008 Lippincou Williams & Wilkins Open Versus Arthroscopic Stabilization FIGURE 7 Arrow points to knot tying instrument pushing knot down suture limb retrograded through the Inferior glenohur ‘meral ligament labrum onto the effect. 10. AGHL), Pushing knot down this limb "rolls" ‘Slencid face, helping to restore the "bumper" loop security should match the quality of knots ted in an Sopot forthe remaining anchor opt 6 to9 ace repeated for tne anchor, care- fully shifting tissue in a superior direction with each eda. tional enchor. When completed, tension within the pleno- ‘humeral igaments shouldbe restored and alabal “bump. er" created (Figs. 8A, 8B) Once the Banka lesion kas been repaired, additonal sular plication stches can be placed ifeomed necessary for espsular redundancy. Ifa patulons interval is noted atthe time ofthe diagnostic Portion of the arthroscopic procedure, on completion of the Bankart repair, a rats interval clasureis completed. My technique is one of placing two #1 PDS sutures through the most superior portion of the rotator interval and then retsieving cach with an angled penetrating device that hasbeen introduced through the low anterior cannule and bas already pierced a portion ofthe mide glenoin. ‘eral ligament (Fig 9). The two superior sutures are cap. tured with a crochet hook and brought through the low anterior portal where the sutures are tied in an extra. capsular fashion. My concer for over-constaining the in. terval and limiting rotation is reflected in the use of ab. sorbable suture, Postoperative care shouldbe individualized, but should include immobilization fora minimum of 3 0 4 weeks, The combined abducted-externally rotated position shouldbe avoided for atleast 2 months. Range of motion goals should proceed cautiously with 9094 of motion Achieved at 3 months post operatively. A return to contact or callsion sports is permited 5 months following sus. ery 95FIGURE & A, Re-created labral "bumper* viewed from the anterlor-supertor portal. Tension has been restored to the gle- Aohumend ligaments. B, Labral “bumper” viewing from the posterior portal. CONCLUSION Given the advantages ofthe arthroscopic approsch, can current arthroscopic techniques, carefully detailed in the list, reliably overcome the multiple risk factor alluded to earlier? From 1984 to 2000, the literature did not support the routine ‘use of arthroscopic stabilization forthe general orthopedist be- cause only a handful of clinicians could attain success rates comparable to the open techniques. Since 2000, with the ad- vent of improved techniques in combination with a better ap- preciation forthe patboanatomy, one can reasonably conchude that arthioscopic stabilization isa valid altemative to open re- construcon in properly selected cases. Curent literature sup- ports the concept tht recurrence rate for both open and ar Ubroscopic stabilization procedures are converging and range from 5% to 10%. ‘When trying to decide between open and arthroscopic procedures, the most important question tobe answered by the {individual clinician is “Whats an acceptable recurrencerate in 96 2ports med Artinrose Rev » Volume 12, Number 2, June 2004 FIGORE'B Spinal Rese loaded with'#¥ PDS passed Behind the biceps (8); grasper placed through low canhula, penetra ing the middle glenchumeral ligament (MGHL). Knot ted ex. eeapaubr, ‘my practice?” The answer will be different forall of usand will reflect th patient population we are treating. The orthopedist striving to maintain the highest level of skill and ability in 5 professional pitcher may bave very different goals when treat. ing instability in a classroom teacher. Bach clinician must do- ‘ermine the risk factors facing each of their patients with shoul- der instability, and should then candidly discuss theso factors ‘With the patient. Once all of the risk factors have been ident- fied und discussed, both the surgeon and patient will be com- ‘ited tothe final surgicel solution whether it be open or ar- thoscopio. fan acceptable recurrence rate isto be maintained utilizing arthroscopic techniques, several variables must be considered when making a decision of open versus atthro- copie 1. Skill and experience ofthe operating surgeon 2, Expectations of the patient 3. Anetomic risk factors: 4, Sightficant bone loss 5. Geriralized ligamentous laxity 6. IGHL quality 17. Nos-anatomic risk factors 8. Younger age 9. Contact sports Forthe younger contact athlete or for those with signfi- ‘ant lonoid or humeral head bony deficiencies or severe as- sociated ligamentous laxity, an open shoulder reconstruction ay bi the procedure of choice. Absent these risk factors, r- throscopic stabilization is a vinble alterative to the open tech- niques, At the time of surgery, the goals achieved in open sur- ety must be duplicated during the arthroscopic approach, namely restoration ofthe appropriate resting length of the gle- nohumeral ligaments, closure of the Bankart lesion, and re- creation ofthe labral “bumper”, al of which can be accom. plished by folowing meticulous technique, © 2006 Lippincon Williams & Wilkinssports Med Arthrosc Rev * Volume 12, Number 2, june 2004 Ona final note, immediate arthroscopic stabilization of the firsttime dislocator who is at the high risk for recur- reace™* may be the best circumstance for arthroscopic sta- bilization. The considerations are analogous to the acute ante- rior cruciate ligament injury.* Rarely do we advise our high- risk knee patients to compete and to experience a severe pivot shit episode, risking further damage to articular cartilage and menisci, before deciding to proceed with stabilization of the ‘knee, In the high-risk shoulder instability group, the risk for further damage is present,”°* and the results following late reconstruction can be jeopardized. The surgical enviroument for healing is ideal following the initial dislocation, and the ‘complex iSsue of eapsular elongation can be avoided. By pre- ‘eating further episodes of instability, capsular damage is ob- viated and, progressive bone loss from either the glenoid ot bbumeral head is likewise precluded, REFERENCES }, RoweCR, Pus! D, Southmayd WW. The Bena procedare:longteca tnd reel tty J Bone Join Seg i78:60A:1-16 2, With, BlterG, Rockwood © The cepa incision procolre for scart anterior instability ofthe boule. 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A pompectie embaton comparing srtvoscople and open ”