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V60 n3 4-3

  1. 1. 124 Bulletin • Hospital for Joint Diseases Volume 60, Numbers 3 & 4 2001-2002 Arthroscopic Stabilization of Anterior Shoulder Instability A Historical Perspective Drew A. Stein MD Laith M. Jazrawi MD Jeffrey E. Rosen MD and Mark I. Loebenberg MD T 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.
  2. 2. 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
  3. 3. 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-
  4. 4. 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,
  5. 5. 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 References shoulder stabilization using transglenoid sutures. Am J 1. Hintermann B, Gachter A: Arthroscopic findings after Sports Med 24(4):459-467, 1996. shoulder dislocation. Am J Sports Med 23(5):545-551, 20. Weber EM, Wilk RM, Richmond JC: Arthroscopic Bankart 1995. repair using suture anchors. Op Tech Orthop 1:194, 1991. 2. McFarland EG, Neira CA, Gutierrez MI, et al: Clinical 21. Wolf EM: Arthroscopic capsulolabral repair using suture significance of the arthroscopic drive-through sign in anchors. Orthop Clin North Am 24(1):59-69, 1993. shoulder surgery. Arthroscopy 17(1):38-43, 2001. 22. Snyder SJ, Karzel RP, Del Pizzo W. SLAP lesions of the 3. Detrisac DA, Johnson LL: Arthroscopic shoulder shoulder. Arthroscopy 6:274-279, 1990. capsulorraphy using metal staples. Orthop Clin North Am 23. Silver MD, Daigneault JP: Symptomatic interarticular mi- 24(1):71-88, 1993. gration of glenoid suture anchors. Arthroscopy 16(1):102- 4. Lane JG, Sachs RA, Riehl B: Arthroscopic staple 105, 2000. capsulorraphy: A long-term follow-up. Arthroscopy 24. Kaar TK, Schenck Jr RC, Wirth MA, et al: Complica- 9(2):190-194, 1993. tions of metallic suture anchors in shoulder surgery: A 5. Morgan CD, Bodenstab AB: Arthroscopic Bankart suture report of 8 cases. Arthroscopy 17(1):31-37, 2001. repair: Technique and early results. Arthroscopy 3:111- 25. Harryman II DT, Ballmer FP, Harris SL, et al: 122, 1987. Arthroscopic labral repair to the glenoid rim. Arthroscopy 6. Benedetto KP, Glotzer W: Arthroscopic Bankart proce- 10(1):20-30, 1994. dure by suture technique: Indications, technique, and re- 26. Zuckerman JD, Matsen III FA: Complications about the sults. Arthroscopy 8(1):111-115, 1992. glenohumeral joint related to the use of screws and staples. 7. Grana WA, Buckley PD, Yates CK: Arthroscopic Bankart J Bone Joint Surg 66A:175-180, 1984. suture repair. Am J Sports Med 21(3):348-353, 1993. 27. Speer KP, Warren RF: Arthroscopic shoulder stabiliza- 8. Walch G, Boileau P, Levigne C, et al: Arthroscopic stabi- tion: A role for biodegradable material. Clin Orthop lization for recurrent anterior shoulder dislocation: Re- 291:67-74, 1993. sults of 59 cases. Arthroscopy 11(2):173-179, 1995. 28. Warner JJP, Warren RF: Arthroscopic Bankart repair us- 9. Green MR, Christensen KP: Arthroscopic Bankart proce- ing a cannulated, absorbable fixation device. Oper Trans dure: Two- to five-year follow-up with clinical correla- Orthop 1:192-198, 1991. tion to severity of glenoid labral lesion. Am J Sports Med 29. Warner JJP, Miller MD, Marks P, et al: Arthroscopic 23(3):276-281, 1995. Bankart repair with the Suretac device. Part II: Experi- 10. Youseff JA, Carr CF, Walther CE, et al: Arthroscopic mental observations. Arthroscopy 11(1):14-20, 1995. Bankart suture repair for recurrent traumatic unidirec- 30. Burkart A, Imhoff AB, Roscher E: Foreign-body reaction tional anterior shoulder dislocations. Arthroscopy to the bioabsorbable Suretac device. Arthroscopy 11(5):561-563, 1995. 16(1):91-95, 2000. 11. Caspari RB: Arthroscopic reconstruction for anterior 31. Warner JJP, Miller MD, Marks P, et al: Arthroscopic shoulder instability. Tech Orthop 3:59-66, 1988. Bankart repair with the Suretac device. Part I: Clinical 12. Caspari RB, Savoie III FH, Meyers TF, et al: Arthroscopic observations. Arthroscopy 11(1):2-13, 1995. shoulder reconstruction. Orthop Trans 13:559, 1989. 32. Speer KP, Warren RF, Pagnani M, et al: An arthroscopic 13. Savoie III FH, Miller CD, Field LD: Arthroscopic recon- technique for anterior stabilization of the shoulder with a struction of traumatic anterior instability of the shoulder: bioabsorbable tack. J Bone Joint Surg 78A:1801-1807, The Caspari technique. Arthroscopy 13(2):201-209, 1997. 1996. 14. Reeves B: Experiments on the tensile strength of the an- 33. Laurencin CT, Stephens S, Warren RF, et al: Arthroscopic terior capsular structures of the shoulder in man. J Bone Bankart repair using a degradable tack. Clin Orthop Joint Surg 50A:858-865, 1968. 332:132-137, 1996. 15. Hayashida K, Yoneda M, Nakagawa S, et al: Arthroscopic 34. Kandziora F, Jager A, Bischof F, et al: Arthroscopic la- Bankart suture repair for traumatic anterior shoulder in- brum refixation for post-traumatic anterior shoulder in- stability: Analysis of the causes of a recurrence. stability: Suture anchor versus transglenoid fixation tech- Arthroscopy 14(3):295-301, 1998. nique. Arthroscopy 16(4):359-366, 2000. 16. Marcacci M, Zaffagnini S, Petitto A, et al: Arthroscopic 35. Tauro JC: Arthroscopic inferior capsular split and ad- management of recurrent anterior dislocation of the shoul- vancement for anterior and inferior shoulder instability: der: Analysis of technical modifications on the Caspari Technique and results at 2- to 5-year follow-up. procedure. Arthroscopy 12(2):144-149, 1996. Arthroscopy 16(5):451-456, 2000. 17. Yoneda M, Hayashida K, Izawa K, et al: A simple and 36. Green MR, Christensen KP: Arthroscopic versus open
  6. 6. Bulletin • Hospital for Joint Diseases Volume 60, Numbers 3 & 4 2001-2002 129 Bankart procedures: A comparison of early morbidity and two to six-year follow-up study. J Bone Joint Surg complications. Arthroscopy 9(4):371-374, 1993. 82A:1108-1114, 2000. 37. Sisto DJ, Cook DL: Intraoperative decision making in the 42. Gartsman GM, Taverna E, Hammerman SM: Arthroscopic treatment of shoulder instability. Arthroscopy 14(4):389- rotator interval repair in glenohumeral instability: De- 394, 1998. scription of an operative technique. Arthroscopy 38. Geiger DF, Hurley JA, Tovey JA, et al: Results of 15(3):330-332, 1999. arthroscopic versus open Bankart suture repair. Clin 43. Arciero RA, Wheeler JH, Ryan JB, et al: Arthroscopic Orthop 337:111-117, 1997. Bankart repair versus nonoperative treatment for acute, 39. Roberts SN, Taylor DE, Brown JN, et al: Open and initial anterior shoulder dislocations. Am J Sports Med arthroscopic techniques for the treatment of traumatic an- 22(5):589-594, 1994. terior shoulder instability in Australian rules football play- 44. Kirkley A, Griffin S, Richards C, et al: Prospective ran- ers. J Shoulder Elbow Surg 8(5):403-409, 1999. domized clinical trial comparing effectiveness of imme- 40. Steinbeck J, Jerosch J: Arthroscopic transglenoid stabili- diate arthroscopic stabilization versus immobilization and zation versus open anchor suturing in traumatic anterior rehabilitation in first traumatic anterior dislocations of instability of the shoulder. Am J Sports Med 26(3):373- the shoulder. Arthroscopy 15(5):507-514, 1999. 378, 1998. 45. Boszotta H, Helperstorfer W: Arthroscopic transglenoid 41. Cole BJ, L’Insalata J, Irrgang J, et al: Comparison of suture repair for initial anterior shoulder dislocation. arthroscopic and open anterior shoulder stabilization: A Arthroscopy 16(5):462-470, 2000.