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Fig. 1 A, Intraoperative photo of open capsular repair for anterior instability; the anterior portion of the subscapularis tendon has been released and retracted medially with the entire muscle mass. B, Illustration showing reflection of capsular flaps to expose the joint and enable inspection and repair of a soft-tissue or bony Bankart lesion. Reproduced from Brems JJ: Open capsular repair for anterior instability, in Zuckerman JD (ed): Advanced Reconstruction Shoulder, Rosemont IL, American Academy of Orthopaedic Surgeons, 2007, pp 47-56.

AAOS Now

Published 5/1/2010
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Jennie McKee

Open repair results in less recurrent instability

Study evaluates open, arthroscopic surgical techniques for shoulder repair

“Systematic reviews have evaluated whether an arthroscopic or open technique yields better results in patients with recurrent shoulder instability,” said Nicholas G.H. Mohtadi, MD, MSc, FRCSC. “They have shown that an open procedure is less likely to result in recurrent instability; however, this remains a controversial topic.”

Dr. Mohtadi and other Canadian researchers performed the largest randomized trial to date on this subject and found more evidence in favor of the open technique.

“We found no difference in disease-specific quality of life in patients who received open or arthroscopic repair for traumatic anterior shoulder dislocation,” he asserted, “but patients who underwent open repair had a significantly lower risk of recurrent instability.”

Dr. Mohtadi presented these results during the American Orthopaedic Society for Sports Medicine’s 2010 Specialty Day program.

An expertise-based approach
In the randomized clinical trial, 196 patients with traumatic unidirectional anterior shoulder instability underwent open (Fig. 1) or arthroscopic (Fig. 2) repair (open, n = 98; arthroscopic, n = 98). Both groups consisted of 80 males and 18 females. The mean age in the open group was 27.8 years; in the arthroscopic group, it was 27.2 years. Expertise-based randomization allowed the participating surgeons to perform their preferred surgical technique for the repairs.

“Bankart lesions were the primary pathology, and most of the open procedures were performed using the subscapular split approach,” noted Dr. Mohtadi. “The use of absorbable anchors was similar in both groups.

“In most cases,” he added, “single stitches, rather than double-loaded stitches, were used in each anchor.”

The researchers measured disease-specific quality of life using the Western Ontario Shoulder Instability (WOSI) Index at baseline and at 3, 6, and 12 months postoperatively. They compared mean WOSI scores using an independent sample t-test.

Secondary outcome measures included range-of-motion, recurrent instability, surgical time, and scores from the American Shoulder and Elbow Surgeons (ASES) questionnaire. Patients were followed for a minimum of 1 year, and identical rehabilitation protocols were used.

Fig. 1 A, Intraoperative photo of open capsular repair for anterior instability; the anterior portion of the subscapularis tendon has been released and retracted medially with the entire muscle mass. B, Illustration showing reflection of capsular flaps to expose the joint and enable inspection and repair of a soft-tissue or bony Bankart lesion. Reproduced from Brems JJ: Open capsular repair for anterior instability, in Zuckerman JD (ed): Advanced Reconstruction Shoulder, Rosemont IL, American Academy of Orthopaedic Surgeons, 2007, pp 47-56.
Fig. 2 Arthroscopic evaluation after an initial anterior dislocation. The labrum is robust tissue that has not retracted medially and is in excellent position for arthroscopic repair. Reproduced from Lazarus MD: Acute and chronic dislocations of the shoulder in Norris TR (ed): Orthopaedic Knowledge Update Shoulder and Elbow 2, Rosemont IL, American Academy of Orthopaedic Surgeons, 2002, pp 71-82

Table 1: Shoulder instability recurrence (PDF)

Comparing outcomes
Investigators analyzed baseline characteristics and found no statistically significant differences regarding gender distribution, operative side, hand dominance, age, participation in sports, or WOSI scores between the two groups. On average, arthroscopic procedures were completed in 1 hour and 1 minute, while the open procedures took an average of 1 hour and 17 minutes.

At 12 months postoperatively, 175 patients (84 open, 91 arthroscopic) had completed follow-up. Researchers found no statistical difference in average WOSI scores, ASES scores, or range of motion between the two groups.

A statistically significant difference was found in instability recurrence rates (open, 4 percent; arthroscopic, 12 percent; p = 0.042).

Dr. Mohtadi noted that a logistic regression analysis found that younger age and the presence of a Hill Sachs lesion were two factors related to recurrence.

“All patients with recurrent instability had a Hill Sachs lesion,” he said. “The average age of patients with recurrence was 22 years, compared to 27 years in the total study population.”

Overall, researchers concluded that there is no disease-specific quality of life difference between open and arthroscopic repairs, but that open surgical repair has a statistically lower chance of recurrent instability and a trend toward better disease-specific outcomes.

Dr. Mohtadi was the lead author of “An expertise-based, randomized clinical trial comparing arthroscopic versus open stabilization for recurrent anterior shoulder instability: Disease-specific quality of life outcomes at 12 month follow-up.” His coauthors included Denise S. Chan, MBT, MSc; Robert M. Hollinshead, MD, FRCSC; Richard S. Boorman, MD, MSc, FRCSC; Laurie A. Hiemstra, MD, PhD, FRCSC; Ian K.Y. Lo, MD, FRCSC; Heather N. Hannaford, BKin; Jocelyn Fredine, BKin, CAT(C); Treny M. Sasyniuk, MSc; Elizabeth Oddone-Paolucci, PhD. Dr. Mohtadi and his coauthors reported no conflicts.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom line

  • Both open and arthroscopic approaches for treating traumatic anterior shoulder dislocation have similar functional and quality of life outcomes.
  • Using an open, rather than arthroscopic, technique results in a lower rate of recurrence in patients with recurrent shoulder instability.
  • The presence of a Hill Sachs lesion and younger age are likely associated with recurrent instability.