Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 26, Issue 2 , Pages 239-248, February 2010

Arthroscopic Stabilization for First-Time Versus Recurrent Shoulder Instability

  • Robert C. Grumet, M.D.

      Affiliations

    • Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
    • ,
  • Bernard R. Bach Jr, M.D.

      Affiliations

    • Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
    • , CDR
  • Matthew T. Provencher, M.D., MC, USN

      Affiliations

    • Department of Orthopedic Surgery, Naval Medical Center, San Diego, California, U.S.A.
    • Corresponding Author InformationAddress correspondence and reprint requests to CDR Matthew T. Provencher, M.D., MC, USN, Associate Professor of Surgery, USUHS, Department of Orthopaedic Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Dr, Suite 112, San Diego, CA 92134-1112, U.S.A.

Received 8 May 2009; accepted 11 June 2009. published online 07 December 2009.

Article Outline

Purpose

The purpose of this study was to systematically review the evidence on the outcomes of arthroscopic repair for anterior shoulder instability in first-time dislocators when compared with patients with recurrent instability.

Methods

We designed a systematic review with a specific methodology to investigate the outcomes of surgery for those with only a first-time dislocation versus those who underwent surgery after multiple instability events. We performed a literature search from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials. Key words included the following: first time, primary shoulder, or recurrent shoulder instability, shoulder dislocation, Bankart repair, arthroscopic Bankart repair, and labral repair. The inclusion criteria were cohort studies (Level I to II) that evaluated the outcomes of patients undergoing arthroscopic stabilization after the first dislocation or multiple recurrent episodes. Studies that lacked a comparison group or were retrospective (Level III studies or higher) were excluded.

Results

There were 15 studies that met the inclusion criteria and were included in the final analysis: 5 in the first-time dislocation group and 10 in the recurrent instability group. Study design, patient demographics, mean number of dislocations, surgical technique, and rehabilitation protocol, as well as subjective and objective outcome measures, were recorded.

Conclusions

There were no differences in recurrence or complication rate among patients undergoing surgery after the primary dislocation when compared with those undergoing surgery after multiple recurrent episodes. Clinical outcome measures significantly improved within all independent studies from preoperatively to postoperatively. However, because of variation in the outcome measurement tools used, no direct comparison between the study groups could be performed. Additional randomized controlled studies are needed to compare the functional outcome, quality of life, and ability to return to preinjury activity level among patients undergoing early versus delayed repair for anterior shoulder instability.

Level of Evidence

Level II, systematic review of Level I and II studies.

 

Anterior shoulder instability has been reported to occur in 2% to 8% of the population, most often as a result of trauma to the affected extremity. Several studies have found significant deficits in shoulder function and recurrent episodes of instability after the initial dislocation, particularly in younger patients.1 The rate of recurrent episodes of instability is dependent on the patient's age and activity level at the time of primary dislocation, with male patients at a higher risk than female patients.1, 2 Robinson et al.1 evaluated a prospective cohort of patients aged between 15 and 35 years with anterior shoulder instability. They found that 56% of the patients had recurrent shoulder instability at a mean of 13 months. The highest-risk patients were found to be male patients, aged 20 years or younger, with a recurrence rate of 72% to 86%. Other authors have found similar rates of recurrent instability (RI) in this young, active patient population.2

Because of the high rate of recurrence in this population of patients, many authors have begun advocating early surgical intervention for these “at-risk” patients. Consequently, several studies have evaluated the recurrence rates and outcomes of surgical versus nonsurgical management in cases of first-time (FT) dislocation.3, 4, 5, 6, 7 These authors, as well as evidence-based medicine,8 support early surgical intervention for young male patients because of the high incidence of recurrent dislocation. Advocates for early intervention contend that these patients benefit from surgery because of a dramatically lower recurrence rate when compared with conservative measures. One may also deduce that early intervention allows for a more anatomic repair with “good” tissue, whereas patients with multiple episodes of instability may have attenuation of the anterior structures, making repair more difficult and tenuous at the time of surgery. Finally, authors argue that patients may have an improved quality of life with a more rapid return to preinjury activity level and a lower risk of recurrent episodes.

Open anterior stabilization has been considered the gold standard in the management of the young, active patient with recurrent shoulder instability. By restoring the anatomy of the anterior labrum and capsule to the anterior glenoid, authors have reported a recurrence rate of 3% with the open procedure.9 With the birth of arthroscopic techniques, early attempts to repair the essential lesion of anterior shoulder instability arthroscopically met with inferior results and a recurrence rate of up to 49%.10 However, through the advancement of arthroscopic techniques and a further understanding of the underlying pathoanatomy, arthroscopic labral repair has now proven to be as successful as previous open procedures for recurrent shoulder instability.11, 12, 13, 14, 15, 16, 17

To date, there have been no prospective randomized trials comparing the results of arthroscopic labral repair in patients with FT dislocation versus those with RI. As a result, we devised a systematic review with defined methodology to collect the most relevant information to answer a specific scientific question. The purpose of this systematic review was to critically evaluate the recurrence rate, functional outcome, and quality of life of patients undergoing surgery after the primary dislocation compared with those with multiple episodes. Our hypothesis is that, among a group of patients with similar demographics undergoing a comparable operative technique and rehabilitation protocol, there would be no difference in recurrence rate, functional outcome, or complications between the primary dislocation and multiple episode patients.

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Methods 

The objective of this review was to compare the outcomes of patients with anterior shoulder instability undergoing arthroscopic stabilization after FT dislocation versus those undergoing surgery after multiple RI events. The inclusion criteria for studies in this review were prospective cohort studies with Level I or II evidence that evaluated patients after arthroscopic labral repair for shoulder instability. Any study that lacked a control group (therefore case series) and any retrospective review (Level III studies or higher) was excluded. Any study that could not be translated into the English language or was not in a peer-reviewed journal was also excluded. Patient demographic information, associated pathology, operative technique, objective and subjective outcome measurements, and complications were abstracted from the studies.

Literature Search 

We performed a search of all published literature from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials. Key words included the following: first time, primary shoulder, or recurrent shoulder instability, shoulder dislocation, Bankart repair, arthroscopic Bankart repair, and labral repair. General search terms were chosen to prevent bias and inadvertent exclusion of potential studies.18 Studies that were only presented as abstracts were not included in the final analysis. The references of all relevant articles and review articles were manually cross-referenced to ensure that all possible articles were considered.

Data Acquisition 

Study design, patient demographics, mean number of dislocations, surgical technique, rehabilitation protocol, and subjective and objective outcome measures were recorded for all studies that met the inclusion criteria. Particular attention was paid to the arthroscopic technique, including the repair type (transglenoid, anchors, and so on), number of implants used, and associated pathology found at the time of surgery. When possible, the percentage of satisfied or very satisfied patients in each group was collected. In addition, preoperative and postoperative objective data, including range of motion, strength, clinical outcome scales (Single Assessment Numeric Evaluation; Rowe; Constant; Western Ontario Shoulder Instability Index [WOSI]; Simple Shoulder Test; Disabilities of the Arm, Shoulder and Hand; University of California, Los Angeles; American Shoulder and Elbow Surgeons; Oxford Instability Shoulder Score; visual analog scale; and Short Form 12 Questionnaire Physical Score and Mental Score), patient satisfaction, and complications, were extracted. The data are presented in table format (see “Results” section). Descriptive statistics were provided; however, statistical comparisons were not performed.

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Results 

Literature Search 

There were 3,038 articles that were in the English language and met the initial search criteria mentioned previously. The abstracts of these studies were then reviewed to evaluate the suitability of each study to meet the inclusion and exclusion parameters. There were 17 studies that met the inclusion criteria: 6 in the FT instability treatment group and 11 in the RI group. One article from the FT instability group was excluded because the surgical group was treated with an open rather than arthroscopic repair.19 One article from the RI group was excluded because the article did not mention the number of recurrent episodes in instability patients before surgical repair.20 There were 15 studies that were included in the final analysis: 5 evaluating arthroscopic repair in FT dislocation3, 4, 5, 6, 7 and 10 evaluating arthroscopic repair in patients with RI.11, 12, 13, 15, 16, 21, 22, 23, 24, 25

Patient Demographics 

The study design, level of evidence, number of patients enrolled, follow-up, patient age, duration of symptoms, and number of episodes of instability were extracted from the studies (Table 1). In the primary instability group there were 4 randomized controlled trials (Level I) and 1 nonrandomized prospective cohort study (Level II). The RI group had 6 randomized controlled trials (Level I) and 4 prospective cohort studies (Level II). The number of patients enrolled in the FT instability group ranged from 10 to 43, with an effective follow-up of 84% to 100%. The RI studies' enrollment ranged from 18 to 130, with an effective follow-up of 95% to 100%. All patients in the FT dislocation group had surgery after the first episode of instability at a mean of 5.5 to 10 days after the traumatic episode. Patients in the RI group had a mean of 3 recurrent episodes to “multiple” recurrent episodes and had a mean duration of symptoms of 22 to 58 months before surgical intervention. In each study the demographics of the study groups were compared, and we did not find any statistically significant differences in age, dominant extremity, gender, follow-up, concomitant pathologies, number of episodes, or time to surgery.

Table 1. Study and Patient Demographics
SourceStudyLevel of EvidenceTotal No. of ShouldersNo. of Shoulders EvaluatedEffective Follow-upDominantMean Age at Surgery (yr)Mean Follow-up (mo)% of Male PatientsCollision Sport (%)Symptom Duration (mo)Mean No. of EpisodesMean Time to Surgery (d)
FT
Arciero et al.,3 1994Pro, NRII2121100%43%20.532N/R43%N/A15.5
Bottoni et al.,4 2002Pro, RI10990%40%21.635100%70%N/A1<10
Kirkley et al.,5 1999Pro, RI1919100%47%22.131.784%N/RN/A1N/R
Kirkley et al.,6 2005Pro, RI191684%44%22.17981%N/RN/A1N/R
Robinson et al.,7 2008Pro, RI433684%44%24.32493%N/RN/A17.6
RI
Bottoni et al.,11 2006Pro, RI3232100%44%25.228.597%N/R35.1Multiple
Cole et al.,12 2000Pro, NRII393795%49%285289%57%35Multiple
Fabbriciani et al.,13 2004Pro, RI3030100%73%24.52480%N/R25.33.2
Jorgensen et al.,15 1999Pro, RI2121100%24%2836.271%N/R513 to 32
Karlsson et al.,16 2001Pro, NRII60N/RN/RN/R262875%N/R316
Kartus et al.,21 1998Pro, NRII18N/RN/R50%3228N/RN/R274
Sperber et al.,22 2001Pro, RI3030100%70%252470%N/R57.6>1
Steinbeck and Jerosch,23 1998Pro, NRII3030100%80%27.53677%N/RN/R6.35
Tan et al.,24 2006Pro, RI130124(63)95%63%2731.285%N/R21.6>1
124(61)95%54%2828.888%N/R25.2>1
Magnusson et al.,25 2006Pro, RI4040(20)100%60%262570%N/R343
40(20)100%60%302670%N/R345

Abbreviations: Pro, prospective; NR, nonrandomized; N/R, not recorded; N/A, not applicable; R, randomized.

Surgical Technique 

All studies described an arthroscopic method for repair of the essential “Bankart” lesion (Fig 1, Table 2). Three studies in the FT group described a transglenoid technique26 for labral repair with a mean of 2 sutures.3, 5, 6 One study in the FT group used a mean of 2.1 bioabsorbable tacks (Suretac; Smith & Nephew Endoscopy, Andover, MA) for repair,4 and one study used a mean of 4.2 suture anchors (Panalok; DePuy Mitek, Raynham, MA).7 In the RI group 2 studies performed a transglenoid technique for repair.15, 23 Five studies used between 2 and 3 knotless bioabsorbable tack devices for fixation (Suretac [Smith & Nephew Endoscopy] or Bionx [Linvatec, Largo, FL]).12, 16, 21, 22, 25 The remaining 3 studies repaired the Bankart lesion with 3 to 5 suture anchors including both metal anchors (mini-Revo [Linvatec] or GII [DePuy Mitek])13, 24 and absorbable anchors (Bio-FASTak [Arthrex, Naples, FL] or Panalok [DePuy Mitek])11, 24 (Video 1, available at www.arthroscopyjournal.org). All implants were placed in an effort to reproduce the anatomy of the anteroinferior labrum and restore the “bumper” of the capsulolabral complex (Fig 2).

  • View full-size image.
  • Figure 1. 

    Arthroscopic image of a classic Bankart lesion in a right shoulder. The anteroinferior labrum is avulsed from the anterior glenoid (arrow). The patient in this image is in the left lateral decubitus position. The arthroscope is in the posterior viewing portal looking anterior across the glenoid surface.

Table 2. Surgical Technique
SourceSurgical TechniqueNo. of Points of FixationLabrum-Bone FixationConcomitant PathologyBony BankartRehabilitation
FT
Arciero et al.,3 1994Arthro2TGSLAP (2), HS (19)24%I: 4 wk
Bottoni et al.,4 2002Arthro2.1BT (Suretac; SNO)SLAP (2), HS (10) I: 4 wk, AA: 4 wk, S: 4 wk, RTS: 4 mo
Kirkley et al.,5 1999Arthro2TGSLAP (1), HS (18) I: 3 wk, AA: 4-6 wk, S: 9 wk, RTS: 4 mo
Kirkley et al.,6 2005Arthro2TGSLAP (1), HS (18) I: 3 wk, AA: 4-6 wk, S: 9 wk, RTS: 4 mo
Robinson et al.,7 2008Arthro4.2SA (Panalok; DM)SLAP (8), HS (45)9%I: 6 wk, AA: 6-12 wk, S: 12 wk
RI
Bottoni et al.,11 2006Arthro5SA (Bio-FASTak; Arthrex)SLAP (8), Bankart (8), ALPSA (19) I: 4 wk, A: 4-8 wk, S: 8 wk
Cole et al.,12 2000Arthro2 to 3BT (Suretac; SNO)Excluded I: 4 wk, S: normal ROM, RTS: 8 mo
Fabbriciani et al.,13 2004Arthro3SA (mini-Revo; Linvatec)Excluded I: 3 wk, S: 3 mo, RTS: 6 mo
Jorgensen et al.,15 1999ArthroN/RTGHS (21)5%I: 3 wk, P/A: 3-6 wk, RTS: 12 wk
Karlsson et al.,16 2001ArthroN/RBT: extra-articular (8), intra-articular (52) (Suretac; SNO)N/R I: 4 wk, A: 4 wk, S: 6 wk, RTS: 6 mo
Kartus et al.,21 1998Arthro2.55BT: intra-articular (11), extra-articular (7) (Suretac; SNO)N/R I: 4 wk, A: 4 wk, S: 4 wk, RTS: 6 mo
Sperber et al.,22 2001Arthro2BT (Suretac; SNO)N/R I: 3 wk, A: 6 wk, RTS: 6 mo
Steinbeck and Jerosch,23 1998ArthroN/RTGHS (30) I: 4 wk, A: 6 wk, RTS: 6 mo
Tan et al.,24 2006Arthro3SA (GII; DM)SLAP (6)3%I: 3 wk, A: 3 wk
Arthro3SA (Panalok; DM)SLAP (6)3%I: 3 wk, A: 3 wk
Magnusson et al.,25 2006Arthro2.88BT (Bionx; Linvatec)Excluded I: 4 wk, S: 4 wk, RTS: 6 mo
Arthro2.88BT (Suretac; SNO)Excluded I: 4 wk, S: 4 wk, RTS: 6 mo

Abbreviations: Arthro, arthroscopic; TG, transglenoid; HS, Hill-Sachs; I, immobilization; BT, bioabsorbable tack; SNO, Smith & Nephew Endoscopy; AA, active assisted range of motion; S, strength; RTS, return to sport; SA, suture anchor; DM, DePuy Mitek; ALPSA, anterior labroligamentous periosteal sleeve avulsion; ROM, range of motion; P, passive range of motion; A, active range of motion; N/R, not recorded.

  • View full-size image.
  • Figure 2. 

    Arthroscopic image of right shoulder after repair of labral tear with suture anchors. There is restoration of the labral “bumper” (arrow). The patient in this image is in the left lateral decubitus position. The arthroscope is in the posterior viewing portal looking anterior across the glenoid surface.

Concomitant SLAP pathology and repair were described in 5% to 20% of patients with FT instability3, 4, 5, 6, 7 and in 2 studies (10% to 25%) in the RI group.11, 24 The remainder of the studies either excluded patients with additional pathology12, 13, 25 or did not mention concomitant pathology.15, 16, 21, 22, 23 The incidence of an associated Hill-Sachs lesion at the time of arthroscopy ranged from 90% to 100%. Bottoni et al.,11 in the RI group, further divided the patient group into those with Bankart lesions at the time of arthroscopy (25%) and those with anterior labroligamentous periosteal sleeve avulsion, which was found in 59% of patients. Finally, the incidence of an osseous bony Bankart lesion ranged from 9% to 24% in the FT instability group3, 7 and from 3% to 5% in the RI group.15, 24 All authors described the bony pathology as involving less than 20% of the glenoid surface and being incorporated into the repair at the time of surgery.

Rehabilitation 

The postoperative rehabilitation protocol was similar among all studies evaluated and included a period of immobilization for 3 to 6 weeks postoperatively, followed by an active range-of-motion program at 3 to 6 weeks and strengthening at 6 to 12 weeks. Patients were allowed to return to their preinjury sport at a mean of 4 to 8 months postoperatively.

Recurrence 

The five studies describing surgical repair for FT instability had a recurrence rate of 7% to 16% (Table 3). Three studies that described a transglenoid suture technique for repair of the anteroinferior capsulolabral complex had the highest rates of recurrence in this group, at 15% to 16%.3, 5, 6 The one study that described fixation with a bioabsorbable tack had an overall recurrence rate of 11%.4 The lowest recurrence rate was seen in the patients with suture anchor repair of the Bankart lesion, at only 7%.7 There was some variation in the definition of “failure” and therefore “recurrence.” Arciero et al.3 and Bottoni et al.4 defined recurrence as any episode of repeat dislocation or if there was any subjective experience of instability. Robinson et al.7 used the same definition, plus additional confirmation by positive apprehension on examination. The remaining 2 studies in the FT instability group simply defined failure and recurrence as any repeat episode of dislocation postoperatively and did not include any subjective complaints or evidence of instability by examination.5, 6

Table 3. Recurrence Rate, Technique, and Description of Failure
SourceLabrum-Bone FixationOverall RecurrenceMean Time to Recurrence (mo)Failure Definition
FT
Arciero et al.,3 1994TG15% Subluxation or dislocation
Bottoni et al.,4 2002BT (Suretac; SNO)11% Subluxation, dislocation, inability to full active duty, or second procedure
Kirkley et al.,5 1999TG16% Dislocation
Kirkley et al.,6 2005TG16% Dislocation
Robinson et al.,7 2008SA (Panalok; DM)7%11.3Subluxation or dislocation plus apprehension on examination
RI
Bottoni et al.,11 2006SA (Bio-FASTak; Arthrex)4% Pain only, no instability
Cole et al.,12 2000BT (Suretac; SNO)24% Subluxation, dislocation, or positive apprehension on examination
Fabbriciani et al.,13 2004SA (mini-Revo; Linvatec)0% Subluxation or dislocation
Jorgensen et al.,15 1999TG10% Subluxation, dislocation, or positive apprehension on examination
Karlsson et al.,16 2001BT: extra-articular (8), intra-articular (52) (Suretac; SNO)15% Subluxation or dislocation
Kartus et al.,21 1998BT: intra-articular (11), extra-articular (7) (Suretac; SNO)0% Dislocation
Sperber et al.,22 2001BT (Suretac; SNO)23%13Subluxation or dislocation
Steinbeck and Jerosch,23 1998TG17%/30% Dislocation or positive apprehension on examination
Tan et al.,24 2006SA (GII; DM)6% Dislocation or positive apprehension on examination
SA (Panalok; DM)11% Dislocation or positive apprehension on examination
Magnusson et al.,25 2006BT (Bionx; Linvatec)5%/45% Dislocation/discomfort at maximal ER and no instability
BT (Suretac; SNO)5%/15% Dislocation/discomfort at maximal ER and no instability

Abbreviations: TG, transglenoid; BT, bioabsorbable tack; SNO, Smith & Nephew Endoscopy; SA, suture anchor; DM, DePuy Mitek; ER, external rotation.

The 10 studies that evaluated arthroscopic Bankart repair after multiple episodes of RI had a recurrence rate of 0% to 30% (Table 3). In the 2 studies that evaluated the effectiveness of a transglenoid suture technique for arthroscopic repair, the recurrence rate was 10% to 30%.15, 23 These authors defined recurrence as a repeat episode of dislocation or a subjective complaint of subluxation confirmed by positive apprehension on examination. Steinbeck and Jerosch23 described variable recurrence rates: 17% among patients with dislocation only versus 30% among those with either an episode of dislocation or subjective subluxation. The 5 studies that performed fixation with a variable number of knotless bioabsorbable tack devices had recurrence rates of 0% to 24%.12, 16, 21, 22, 25 All of the authors performing bioabsorbable tack fixation described failure as any recurrent episode of dislocation or subluxation. Magnusson et al.25 also evaluated patients' discomfort at maximal external rotation and found that 15% to 45% of patients had pain with this provocative maneuver but no sense of instability. Finally, the 3 studies with suture anchor fixation described recurrence rates of 0% to 11%.11, 13, 24 Recurrence was again defined as shoulder dislocation or subjective subluxation.

Postoperative Range of Motion, Strength, and Outcome Scores 

There was great variation in the tools used to measure patient outcome postoperatively among the studies reviewed (Table 4). Within each independent study, there was a statistically significant improvement in outcome scores from preoperatively to postoperatively. However, the only comparison in outcome measures between groups was in Rowe scores. Eighty-eight percent of patients reported a good or excellent Rowe score in the FT dislocation group after bioabsorbable tack fixation4 compared with 76% to 99% of patients with similar fixation in the RI group.12, 21 Because of the variability in outcome measures recorded or arthroscopic technique, however, no other direct comparison could be made between FT instability and RI outcome measures. Similarly, variation in technique for range-of-motion and strength measurements prevented an accurate comparison between the FT and RI groups. However, among the FT instability group, patients regained greater than 85% of external rotation (neutral abduction), 95% of forward elevation, 93% of external rotation at 90° of abduction, and 98% of internal rotation when compared with the unaffected extremity.5 Similarly, patients in the RI group regained nearly 100% of forward elevation and abduction, 90% of external rotation (neutral abduction), and 80% to 90% of external rotation at 90° of abduction and were within 1 level of internal rotation compared with the nonoperative extremity.11, 12, 16, 21, 22, 25

Table 4. Clinical Outcomes
SourceConstantOISSVASSF-12 PSSANERoweRoweWOSIDASHSSTUCLAASESRTSSatisfaction
ExcellentGoodFairPoor
FT
Arciero et al.,3 1994 88 76%10%0%14%
Bottoni et al.,4 2002 67%22%0%11%
Kirkley et al.,5 1999 287.01(290.19)
Kirkley et al.,6 2005 95.8 94.7
Robinson et al.,7 2008 ∼98 94%
RI
Bottoni et al.,11 2006 93.5(8.3)91.6 433.6(443.6) 11.4(1.2)32.1(2.7)
Cole et al.,12 2000 8362%14%19%5% 8746%84%
Fabbriciani et al.,13 200489.5(4.25) 91(15.06)
Jorgensen et al.,15 199962 92.5
Karlsson et al.,16 200191 93
Kartus et al.,21 199896 9267%33%0%0%
Sperber et al.,22 2001100 100
Steinbeck and Jerosch,23 1998 83.1(21.6) 83%
Tan et al.,24 2006 18(6)0.3(0.7)50(9) 85%
20(10)0.7(1.6)54(8) 85%
Magnusson et al.,25 200684 90
87 90

NOTE. Values are mean (standard deviation).

Abbreviations: OISS, Oxford Instability Shoulder Score; VAS, visual analog scale; SF-12 PS, Short Form 12 Questionnaire Physical Score; SANE, Single Assessment Numeric Evaluation; DASH, Disabilities of the Arm, Shoulder and Hand; SST, Simple Shoulder Test; UCLA, University of California, Los Angeles; ASES, American Shoulder and Elbow Surgeons; RTS, return to sport.

Complications 

There were few complications recorded among patients in either group. Among patients undergoing surgery after primary dislocation, 2 patients had adhesive capsulitis postoperatively, described as a “severe” restriction in external rotation.7 One of the two patients was successfully treated with an aggressive course of physical therapy and the other with an arthroscopic release of the rotator interval and capsule followed by manipulation under anesthesia. Two patients had transient median nerve paresthesias that resolved by 3 weeks postoperatively,3 and two patients had superficial infections.3, 7 In the RI group 7 patients had adhesive capsulitis postoperatively with a “severe” restriction in range of motion.12, 16, 25 Of these 7 patients, 3 had resolution of their symptoms after a course of physical therapy, 3 required additional surgery to regain motion, and in 1 moderate osteoarthritis developed.25 The RI group also had 2 patients with anchor pullout,16, 22 1 with a transient paresthesia (ulnar sensory), 3 with a superficial infection, and 8 with painful sutures or incisions that resolved by the final follow-up.15, 22, 25

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Discussion 

The technique of and surgeon experience with arthroscopic Bankart repair for shoulder instability have now evolved to the point that the results of arthroscopic repair are at least equal to those of the gold standard open repair technique.14 The arthroscopic technique has shown clear improvement in patient subjective and objective outcome scores with a low risk of complications.11, 12, 13, 16, 21, 22, 24, 25 In addition, several studies have supported early versus late surgical repair in young active patients for shoulder instability.3, 4, 5, 6, 7, 19 The argument in favor of early repair includes a reduction in recurrence rate of 70% to 90% when compared with conservative treatment. In addition, some investigators believe that earlier surgery prevents the development of additional intra-articular pathology, including glenoid bone loss, increased frequency of Hill-Sachs lesions, and more extensive chondral injuries. Studies have shown significant attrition of the capsular and bony structures with recurrent episodes of instability, which may lead to poor tissue quality and difficulty in reproducing normal anatomy.27, 28 At the time of definitive surgery in these patients, one may expect diminished outcomes when compared with those with more healthy, intact tissue at the time of the initial injury. Finally, there has been little information about quality of life in patients with recurrent shoulder instability. One may presume that a low recurrence rate after primary repair and a rapid return to preinjury activities would allow for improved quality of life compared with those having countless episodes of recurrence over months and years with an inability to return to a normal active life. However, there is very little objective measurement of the patient's quality of life after a shoulder dislocation.

The purpose of this systematic review was to try to answer the question: Does arthroscopic repair in patients with anterior shoulder instability after the primary dislocation improve the recurrence rate, functional outcome, or quality of life when compared with those having surgery after multiple episodes of instability? On the basis of the collection of studies gathered to answer this question, there is no apparent difference in overall recurrence or complication rate among patients undergoing surgery after the initial dislocation compared with those repaired after RI. More specifically, when comparing the type of arthroscopic procedure performed, including modern techniques of suture anchor fixation, there is no difference in recurrence. Rates after arthroscopic suture anchor fixation approach those of open techniques.9 With regard to functional outcome, there was significant improvement in outcome from preoperative to postoperative assessment among independent studies. However, because of the large variability in outcome measures recorded, a true comparison between the outcome variables of patients with FT dislocation and patients with RI was not possible. To assist with cross-comparison of instability studies, it would be prudent in the future to adopt a standardized instability outcome score.

The question of improved quality of life could not be specifically evaluated in this systematic review. However, 1 study evaluated the long-term results after arthroscopic Bankart repair in patients with FT dislocation using the WOSI.6 The WOSI is an outcome instrument used to specifically describe the impact of the patient's shoulder instability on his or her quality of life. Kirkley et al.6 found an 11% difference in WOSI score at a mean of 79 months postoperatively when compared with patients treated nonoperatively. Although the difference between the 2 groups was not found to be statistically significant, the authors concluded that it was a “small but clinically meaningful difference.” To our knowledge, this is the only scientific study that has specifically sought to answer the question: does early surgical intervention improve a patient's quality of life?

Robinson et al.1 evaluated the functional outcome and risk of recurrence in a group of active, “high-risk” patients treated with conservative measures after an episode of shoulder instability. They found that instability developed in 56% of patients within the first 2 years after the primary dislocation and increased to 67% by the fifth year of follow-up. They also noted a small difference in functional outcome as measured by the WOSI. This study also suggests that recurrent shoulder instability negatively impacts a patient's ability to return to preinjury activity level and, therefore, quality of life.

Study Limitations 

As with any systematic review, there are limitations to this study.

Selection Bias 

All of the studies in this systematic review were cohort studies (Level I and Level II). All of the studies provided statistical analysis to ensure homogeneity between comparison groups and therefore limit the potential for selection bias. In addition, 10 of the 15 studies evaluated were randomized prospective clinical studies, which limit bias by experimental design. The factors that have been shown to affect clinical outcome, including age, gender, number of episodes, time to surgery, concomitant pathology, and surgical technique, were not found to be statistically significant between groups in each study.

Performance Bias 

The technique for arthroscopic repair was variable between the FT and RI groups. Within each group, there were patients with transglenoid fixation, bioabsorbable tack fixation, and suture anchor fixation. The variation in technique reflects the evolution in surgical repair for shoulder instability over the years. We attempted to limit performance bias by only comparing recurrence rates among patients receiving a similar arthroscopic procedure. Ideally, to eliminate performance bias, we would have preferred to have all patients having identical surgical repair with a similar number of fixation devices, with elimination of the “learning curve” shown arthroscopic stabilizations.

Performance bias may also occur in studies where a disproportionate number of concomitant procedures were performed or there was variation in the rehabilitation protocol. Patients in the FT dislocation group all had concomitant SLAP repair; however, only 2 studies in the RI group had SLAP repair at the time of the Bankart repair.11, 24 The rehabilitation protocol was not significantly different between groups.

Exclusion Bias 

Exclusion bias was limited in this systematic review because all included studies had greater than 80% (84% to 100%) follow-up, with a mean follow-up near 90%.

Detection Bias 

All of the outcome measures used in this study have been validated as valuable outcome instruments. All studies reported a significant improvement between preoperative and postoperative assessment within each group. The only comparison in outcome measures between groups was in Rowe scores after bioabsorbable tack fixation, as mentioned.4, 12, 21 The remainder of outcome measures either were not recorded in the other studies or were not comparable because of differences in the fixation technique.

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Conclusions 

There were no significant differences in the recurrence rate of instability or complication rate among young active patients undergoing arthroscopic repair for shoulder instability performed after either the primary dislocation or multiple episodes of recurrence. Although there were no apparent differences in outcomes between the FT and RI groups, additional studies are necessary to identify clinical outcome differences between these 2 patient populations. Additional randomized controlled trials are needed to specifically compare the functional outcome, quality of life, and ability to return to preinjury activity level among patients undergoing early versus delayed repair for anterior shoulder instability.

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Video 1. Arthroscopic technique for labral repair associated with instability. The patient in this video is in the lateral position, and the arthroscope is in the anterosuperior portal, with instrumentation passed through the anteroinferior portal. This patient has an associated inferior and posterior labral injury that has already been repaired. The image shows evidence of the Bankart lesion, which has healed medial on the glenoid neck. The labrum is first elevated from the glenoid rim until the underlying subscapularis muscle is exposed. The bone is then decorticated to expose a bleeding bony surface by use of a rasp or bur. A suture anchor is then placed on the glenoid rim, and the suture is shuttled through the labrum, with care taken to advance and imbricate a portion of the anterior-inferior capsule with the labral repair. The suture is then tied by standard arthroscopic techniques.

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 The authors report no conflict of interest.

 

Note: To access the video accompanying this report, visit the February issue of Arthroscopy at www.arthroscopyjournal.org.

PII: S0749-8063(09)00518-0

doi:10.1016/j.arthro.2009.06.006

Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 26, Issue 2 , Pages 239-248, February 2010