124 Bulletin • Hospital for Joint Diseases Volume 60, Numbers 3 & 4 2001-2002
Arthroscopic Stabilization of Anterior
A Historical Perspective
Drew A. Stein MD Laith M. Jazrawi MD Jeffrey E. Rosen MD and Mark I. Loebenberg MD
he treatment of recurrent anterior glenohumeral proper patient selection continues to evolve. Most
instability has been a topic of debate in the recent previous reports of arthroscopic stabilization have
literature. Current operative management of included small numbers of patients, variable patient
shoulder instability has included a variety of open and pathology, and a variety of surgical techniques, making
arthroscopic surgical procedures. Open techniques for comparisons between stabilization procedures difficult.
anterior reconstruction have been quite successful in Arthroscopy can be valuable in both the confirmation of
preventing recurrent dislocations and continue to be the the degree and severity of the instability and to
gold standard of care. In an attempt to address some of potentially correct the pathoanatomy responsible for the
the disadvantages associated with open procedures, instability.
arthroscopic stabilization procedures have been
developed. Arthroscopic capsuloligamentous repair has Arthroscopic Findings
several clear advantages including better cosmesis, The value of diagnostic shoulder arthroscopy is gener-
decreased peri-operative morbidity, and a possible ally well accepted. When used as an adjunct to open sta-
decrease in the loss of external rotation. Advances in bilization, it provides excellent information about the
arthroscopic equipment and improved arthroscopic pathology involved, confirms or redefines a pre-opera-
techniques have increased the popularity of arthroscopic tive diagnosis, and allows for treatment of intra-articu-
stabilization. Recent improvements in the results of lar pathology. Hintermann and Gachter performed shoul-
arthroscopic stabilization are related to the understanding der arthroscopy on 212 patients with documented
that the Bankart lesion is not the “essential lesion” shoulder dislocations. They reported a high variability
surgeons once thought. The art of diagnosing the in pathologic lesions associated with glenohumeral in-
anatomic pathology associated with instability and stability, including anterior glenoid labral tears (87%),
anterior capsule deficiency (79%), Hill-Sachs lesions
Drew A. Stein, M.D., is an Administrative Chief Resident, NYU- (68%), glenohumeral ligament disruptions (55%), rota-
Hospital for Joint Diseases Department of Orthopaedic Surgery, tor cuff tears (14%), posterior labral tears (12%), and
New York. Laith M. Jazrawi, M.D., is an Administrative Chief SLAP (superior labrum, anterior to posterior) lesions
Resident, NYU-Hospital for Joint Diseases Department of Or- (7%).1
thopaedic Surgery, New York. Jeffrey E. Rosen, M.D., is the Di- McFarland prospectively evaluated 339 patients under-
rector of Child and Adolescent Sports Medicine Center, NYU- going shoulder arthroscopy. Pre-operative examination,
Hospital for Joint Diseases Department of Orthopaedic Surgery, examination under anesthesia, arthroscopic intra-articular
and Assistant Professor of Orthopaedic Surgery, New York Uni-
pathology, and the “drive-through” sign were recorded. The
versity School of Medicine, New York. Mark I. Loebenberg, M.D.,
“drive-through” sign was positive in 69% of patients, with
is an Assistant Attending, NYU-Hospital for Joint Diseases De-
partment of Orthopaedic Surgery, and an Assistant Professor of a sensitivity of 92% and a specificity of 37.6% for instabil-
Orthopaedic Surgery, New York University School of Medicine, ity. The “drive-through” sign correlated with increasing
New York, New York. shoulder laxity, but was not specific for instability.2 There-
Reprint requests: Mark I. Loebenberg, M.D., Hospital for Joint fore, many patients may have a positive drive-through sign
Diseases, 301 East 17th Street, New York, New York 10003. without evidence of clinical instability.
Bulletin • Hospital for Joint Diseases Volume 60, Numbers 3 & 4 2001-2002 125
Arthroscopic Procedures tions. Twenty-seven percent experienced a recurrence of
Arthroscopic Stapling instability. All failures were male contact athletes under
In 1982, Detrisac and Johnson performed the first 35 years of age.10
arthroscopic shoulder stabilization procedure, using a Caspari, in 1988, described a technique that allowed
capsular stapling technique.3 This technique was quickly the surgeon to advance and adjust tension in the
abandoned, however, because of hardware problems and capsuloligamentous structures.11 He reported a 4% fail-
an inability to address capsular laxity. Lane and col- ure rate with a 2 to 6 year follow-up.12 Savoie and asso-
leagues retrospectively reported on 54 patients who un- ciates reported a prospective study of 163 patients, fol-
derwent arthroscopic staple capsulorraphy with an aver- lowed for 36 to 72 months, after a transglenoid suture
age follow-up of 39 months. There was a 33% recurrence reconstruction using the Caspari technique; there was a
rate, with 18.5% requiring a subsequent open reconstruc- 9% failure rate. Patients younger than 18 years of age
tive procedure. Fifteen percent developed loose staples had a 26% failure rate. The vast majority (97.5%) of pro-
on follow-up radiographs. Only 43% of athletes were cedures were considered successful for patients over 22
able to return to their pre-injury level of activity.4 years of age.13 This clinical study confirmed previous
anatomic studies reporting weaker labroligamentous at-
Transglenoid Suture Technique tachments to the glenoid in patients who were in their
Since Morgan and associates first described the teenage years.14 In younger individuals significant heal-
transglenoid suture technique for repairing Bankart le- ing may occur; however, it may be at a weaker level and
sions in 1987, many authors have reported variable re- this may increase susceptibility to recurrence.
sults.5 Benedetto and Glotzer reported on 31 patients with Many have attempted to modify the Caspari technique
a follow-up of 2 years with no recurrences.6 Grana and and have experienced recurrence rates similar to those
colleagues reported on 27 patients with a follow-up of reported in the literature.15,16 Modifications have included
36 months and a recurrence rate of 44.4%. Failures were improved preparation of the reinsertion zone on the gle-
attributed to plastic deformation in the capsular tissue noid rim, increased number of sutures, anchorage of the
after shoulder dislocations. Despite the repair of the posterior knots directly on the spine of the scapula, the
Bankart, a component of the instability still existed. Sev- use of a biodegradable polymer button, and the use of
enty-five percent of these failures were in high contact both absorbable and non-absorbable sutures. 16-18
athletes. Failures were also associated with immobiliza- Pagnani and colleagues published a retrospective re-
tion periods of less than one week.7 port with one of the longest follow-ups in the literature.
Fifty-nine patients with recurrent anterior dislocations They reported on 41 patients that were followed for 5
underwent arthroscopic transglenoid suture stabilization years. Nineteen percent had recurrent instability. Four
and were followed for 49 months. Forty-nine percent de- of thirteen contact athletes developed instability within
veloped recurrent instability. Failures in this study were 2 years. The absence of a Bankart lesion was associated
associated with a positive sulcus sign, bony lesions on with a poor outcome.19
the anterior glenoid on radiographs, and extended liga- Disadvantages of the transglenoid technique include
mentous lesions.8 Bony deficiencies and rotator interval the need to tie sutures over the posterior fascia, which
lesions were not addressed surgically and may have ac- places the suprascapular nerve at risk and does not pro-
counted for the increased recurrence rates. vide secure fixation of the knots. The technique has vari-
Green and associates performed arthroscopic able success rates reported in the literature and has since
transglenoid suture fixation on 60 patients with a fol- been abandoned. However, it did pave the way for the
low-up of 41 months; 42% experienced recurrent insta- development of advanced implants to avoid posterior
bility. This study classified labral lesions and correlated fixation. This procedure also began to elucidate poor
this classification with failure rates. In Type I, the gle- prognostic factors for arthroscopic stabilization. Risk
noid labrum and inferior glenohumeral ligament (IGHL) factors for failed arthroscopic stabilization included
complex is normal. Type II is defined by a detachment males under 18 years of age, collision athletes, bone
of the labrum and IGHL complex from the anterior gle- deficiencies on the glenoid, the absence of a Bankart
noid. A Type III lesion is an intra-substance tear in the lesion, an attenuated IGHL complex, rotator interval le-
labrum. Type IV is a detached complex with degenera- sions, and short immobilization periods.
tion and attenuation of the tissue. A Type V lesion is a
completely degenerated or absent complex. Thirteen of Suture Anchors
fifteen patients with Type IV or Type V were failures in The use of suture anchors was initially described by
this study.9 Weber and associates.20 The technique was modified by
Youssef and colleagues reported on 30 patients fol- both Wolf and Snyder who used absorbable and non-ab-
lowed for 38 months after an arthroscopic Bankart re- sorbable sutures, respectively.21,22 This technique has the
pair secondary to traumatic anterior shoulder disloca- advantage of allowing the capsuloligamentous structures
126 Bulletin • Hospital for Joint Diseases Volume 60, Numbers 3 & 4 2001-2002
to be shifted superiorly and be properly tensioned. Com- sive synovitis. Loose fragments of the tack were visualized
plications regarding implants around the glenohumeral in the joint. On histologic examination, there was an infil-
joint can occur. Silver and Daigneault reported on a pa- tration of histiocytes and multinucleated giant cells con-
tient with symptomatic intra-articular migration of a taining birefringent polymeric particles. All cultures were
suture anchor several weeks after placement with result- negative.30 These problems have been addressed with the
ant pain and articular cartilage loss on the humeral head.23 development of newer tacks that have been molded as a
Kaar and colleagues reported on three of eight patients single unit, instead of a body and head, and may increase
with articular damage after complications from improper strength. Changes in the biochemical composition of tacks
placement of metallic suture anchors.24 may reduce the inflammatory response as well.
Osteocompression tacks also may be of value, adding to
Sutures the strength of the implant.
Harryman and associates described a technique of reat- Warner and colleagues, also evaluated 15 patients with
taching the capsuloligamentous structures to the glenoid “second look” surgery after an arthroscopic stabilization
rim with sutures. This technique afforded the advantage using the Suretac anchor. The “second look” procedure was
of fixation without transglenoid drilling, metallic im- performed for recurrent instability or pain after an average
plants, or expensive bioabsorbable anchors. Cadaver of nine months following the index procedure. Biopsies of
models proved the fixation to be adequate and stable.25 two patients with recurrent instability revealed residual
The technique, however, is technically difficult and not polyglyconate polymer debris surrounded by a histiocytic
routinely used at the current time. infiltrate with foreign body giant cells. In the stable shoul-
ders, the Bankart repairs had all either completely or par-
Biodegradable Tacks tially healed. In the patients with recurrent instability, 43%
The use of metallic hardware around the glenohumeral joint of the Bankart lesions did not heal, and 86% had capsular
has been consistently shown to have complications such as laxity. Therefore, the authors stated, selection criteria are
loosening, migration, and breakage, leading to pain and paramount for a successful outcome. Patients with unidi-
arthrosis.26 These problems led to the development of bio- rectional, traumatic anterior instability, with a discrete
degradable tacks for the shoulder. The Suretac device is a Bankart lesion and with well developed glenohumeral liga-
cannulated tack molded from polyglyconate. The head and ments, who do not participate in collision athletics, are ideal
body were molded separately and then attached to each for an arthroscopic procedure.31 Additionally, Speer and
other. Reports of breakage at the junction site have com- associates concluded that the procedure may be accom-
promised fixation. The device is degraded by hydrolysis plished with a tack in patients who do not need capsular
and does not involve an inflammatory process from the volume reduction.32
body. Laboratory studies reveal an approximate 50% loss Laurencin and colleagues used a strict criterion for in-
of strength at 2 weeks and a 100% loss at 4 weeks. Animal dicating the procedure. Indications for selection were trau-
studies showed the heads of the tacks to be loose at 6 weeks matic, unidirectional anterior instability; presence of a
and broken at 12 weeks.27 Bankart lesion; thick IGHL; and minimal bony erosions on
Warner and Warren reported on 20 patients treated with the glenoid. The authors reported a 10% recurrence rate.33
arthroscopic Bankart repair using a biodegradable implant.
Patients were immobilized for 4 weeks. The author found Suture Anchors versus Transglenoid
a 20% recurrence rate after 32 months. There were no com- Fixation
plications associated with the implant.28 Technical pitfalls Several studies have compared results of suture anchors
encountered when using the biodegradable anchors were versus transglenoid fixation. Kandziora and associates
studied by Warner and colleagues on cadaver shoulders. retrospectively studied 163 patients with post-traumatic
Common errors included inadequate abrasion of the gle- shoulder instability requiring labral fixation. Most pa-
noid rim, inadequate superior shift of the IGHL, medial tients (108) were stabilized with a transglenoid suture
placement of the anchor relative to the articular margin, technique, with 55 patients using a FASTak TM suture
and insufficient capture and compression of the capsular anchor. The incidence of recurrence was 32.4% in the
tissue. Initial fixation strength of bioabsorbable tacks (100 transglenoid group and 16.4% in the suture anchor group.
N) may be less than that of open procedures or with suture There was a correlation between the postoperative dis-
repair and, therefore, may require an initial prolonged pe- location rate and the number of preoperative dislocations
riod of immobilization.29 and the degree of labral lesion. The learning curve with
In one case report, Burkart and associates described a the suture anchor group was less steep than with the
foreign-body reaction to the Suretac device. This patient transglenoid technique. The transglenoid group displayed
underwent “second look” arthroscopy, secondary to pain a recurrence rate of 50% when the technique was intro-
and decreased range of motion that occurred at nine weeks duced. This decreased to 11.6% over the next five years.
after the initial surgery. Gross examination revealed mas- The suture anchor technique had a recurrence rate de-
Bulletin • Hospital for Joint Diseases Volume 60, Numbers 3 & 4 2001-2002 127
crease from 22.2% to 10% over a similar period of time. evaluated during arthroscopic stabilization. Arthroscopic
The authors concluded that the suture anchor technique findings consistent with rotator interval tears are capsu-
was superior to the transglenoid, however still inferior lar redundancy between the supraspinatus and subscapu-
to the open technique reported results and that laris, biceps tendon fraying, superior glenohumeral liga-
arthroscopic stabilization may be indicated in a patient ment tears, and fraying of the superior border of the
with less than five preoperative dislocations.34 subscapularis.42 If a surgeon is not comfortable address-
Tauro prospectively reported on 34 patients treated ing this lesion arthroscopically, then an open procedure
with an arthroscopic Bankart repair with a two to five is indicated.
year follow-up. The Bankart repair was combined with
an inferior capsular split that advanced the capsule an Arthroscopic Treatment of Acute Initial
additional 2 cm in an attempt to restored normal capsu- Dislocation
lar tension. A transglenoid suture technique was used in The natural history of traumatic anterior dislocations in
five patients and a suture anchor technique in 29 patients. young patients has been reported to have recurrence rates
The transglenoid group had a recurrence rate of 40%, between 60% and 90%. The West Point Military Acad-
whereas the suture anchor group had a recurrence rate emy conducted a prospective study on non-operative
of 6.9%. The authors summarized that the suture anchor versus arthroscopic Bankart repair after acute, initial dis-
technique was superior to transglenoid technique, and locations. The average age of patients was 20 years.
when combined with a capsular advancement had an Thirty-six patients were included in the report with a
acceptable level of recurrence.35 follow-up of 32 months. Fifteen patients were random-
ized into the non-operative group consisting of one month
Arthroscopic Stabilization versus Open of immobilization followed by rehabilitation. Eighty
Stabilization percent developed recurrent instability. Twenty-one pa-
Recently comparisons between open procedures and tients were in the operative group that had a transglenoid
arthroscopic procedures have been reported in the lit- suture repair of the Bankart lesion. Fourteen percent
erature. Green and Christensen reported that arthroscopic developed recurrent instability. Arthroscopic Bankart
stabilization procedures decreased operating room time, repair reduced the recurrence rate in young athletes af-
blood loss, narcotic use, hospital stay, time lost from ter a primary acute shoulder dislocation.43
work, and complications when compared with open pro- Kirkley and associates performed a prospective ran-
cedures.36 Comparison studies have reported rates of re- domized clinical trial reporting similar recurrence rates
currence between 13% and 70% in the arthroscopic group of 15.9% in the surgical group and 47% in the rehabili-
and 0% and 30% in the open group.37-39 Although initial tation group.44 Boszotta and Helperstorfer reported on
results from the arthroscopic procedures demonstrated 72 patients after a 66 month follow-up; 6.9% developed
significantly higher rates of recurrence, improvements instability. Eighty-five percent resumed sporting activ-
in patient selection and operative technique have steadily ity at their pre-injury level. All patients with recurrence
decreased recurrence rates to match that of open proce- had associated capsuloligamentous injuries combined
dures. with a Bankart lesion.45 Arthroscopic stabilization for
A prospective study on transglenoid suture repair ver- acute, primary traumatic anterior shoulder instability
sus open stabilization revealed a 6% recurrence rate in associated with a Bankart lesion can significantly reduce
the open group and a 17% recurrence in the arthroscopic the rate of recurrence.
group over 36 to 40 months.40 Cole and colleagues re-
ported a prospective study on arthroscopic stabilization Summary
with bioabsorbable tacks versus open repair in which The role of arthroscopic procedures in the management
patients initially had an examination under anesthesia of glenohumeral instability continues to evolve and rep-
(EUA) and diagnostic arthroscopy. Based on the find- resents an effective alternative for addressing the pathol-
ings at arthroscopy, patients were placed in the ogy associated with this condition. Patient selection cri-
arthroscopic group or the open group. Recurrence rates teria, operative techniques, and implants all continue to
were 24% for the arthroscopic group and 18% for the evolve and have resulted in improved rates of success.
open group. This study concluded that both groups Arthroscopic procedures benefit patients by avoiding the
yielded similar results if the procedure was selected on common morbidities associated with the disruption of
the basis of the pathology found at the time of EUA and the anterior soft tissues, including a loss of external ro-
diagnostic arthroscopy.41 tation associated with open procedures. Arthroscopic
procedures remain technically demanding and require
Rotator Interval Repair skills to address all of the existing pathology. The sur-
Rotator interval tears are often associated with gleno- geon must be prepared to address many conditions be-
humeral instability and interval pathology should be yond the Bankart lesions including glenoid bone lesions,
128 Bulletin • Hospital for Joint Diseases Volume 60, Numbers 3 & 4 2001-2002
capsular laxity, rotator interval lesions, and SLAP le- secure anchoring system for Caspari’s transglenoid mul-
sions. In addition to the documentation of recurrence, tiple suture technique using biodegradable poly-L-lactic
the success of this procedure must be evaluated within acid button. Arthroscopy 12:293-299, 1996.
the context of retained ranges of motion, recovery time, 18. Kagaya K, Yoneda M, Hayashida K, et al: Modified
Caspari technique for traumatic anterior shoulder insta-
proprioceptive control, and the return to prior levels of
bility: Comparison of absorbable sutures versus absorb-
activity. Further studies are necessary to continue to vali-
able plus nonabsorbable sutures. Arthroscopy 15(4):400-
date the efficacy of arthroscopic stabilization. 407, 1999.
19. Pagnani MJ, Warren RF, Altchek DW, et al: Arthroscopic
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