Arthroscopic Shoulder Stabilization: Is There Ever a Need to Open?


      Recent studies show comparable results of arthroscopic shoulder stabilization techniques compared with the gold standard open Bankart reconstruction. Great technical advances and ever-increasing surgeon experience have rendered pathology once deemed an indication for open surgery as treatable by arthroscopic means. With this movement toward a more universal application of all-arthroscopic techniques, we might consider the following question: Is there ever a need to open? To answer this question, we must first consider normal anatomy and then appreciate the contribution of deranged pathoanatomy to recurrent instability in each individual case. The surgeon must then determine whether this is best addressed via an arthroscopic or open technique. Arthroscopy, as compared with open stabilization procedures, holds the potential benefits of decreased morbidity rates, early functional rehabilitation, and improved range of motion. Despite potential advantages, arthroscopic stabilization is clearly contraindicated when a significant pathologic lesion contributing to recurrent instability cannot be adequately addressed as a result of the limitations of current techniques or instrumentation. On the basis of this principle, we believe that sizable glenohumeral bone defects remain the only absolute contraindication to an all-arthroscopic approach. Many complicating issues, such as attenuated capsule, humeral avulsion of the glenohumeral ligament lesions, cases of revision surgery, and collision or contact athletes, exist and warrant close attention. We prefer to think of these situations as “challenges” for which both arthroscopic and open surgery should be considered, rather than as true contraindications to arthroscopic shoulder stabilization. We are, by no means, advocating arthroscopic treatment in all cases of shoulder instability, because this would represent a gross oversimplification of the issues at hand. However, we do acknowledge that the steadfast contraindications to arthroscopic shoulder stabilization are decreasing every day.

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        • Green M.R.
        • Christensen K.P.
        Arthroscopic versus open Bankart procedures: A comparison of early morbidity and complications.
        Arthroscopy. 1993; 9: 371-374
        • Stein D.A.
        • Jazrawi L.
        • Bartolozzi A.R.
        Arthroscopic stabilization of anterior shoulder instability: A review of the literature.
        Arthroscopy. 2002; 18: 912-924
        • Sisto D.J.
        • Cook D.L.
        Intraoperative decision making in the treatment of shoulder instability.
        Arthroscopy. 1998; 14: 389-394
        • Geiger D.F.
        • Hurley J.A.
        • Tovey J.A.
        • Rao J.P.
        Results of arthroscopic versus open Bankart suture repair.
        Clin Orthop Relat Res. 1997; : 111-117
        • Freedman K.B.
        • Smith A.P.
        • Romeo A.A.
        • Cole B.J.
        • Bach B.R.
        Open Bankart repair versus arthroscopic repair with transglenoid sutures or bioabsorbable tacks for recurrent anterior instability of the shoulder: A meta-analysis.
        Am J Sports Med. 2004; 32: 1520-1527
        • Bottoni C.R.
        • Smith E.L.
        • Berkowitz M.J.
        • Towle R.B.
        • Moore J.H.
        Arthroscopic versus open shoulder stabilization for recurrent anterior instability: A prospective randomized clinical trial.
        Am J Sports Med. 2006; 34: 1730-1737
        • Cole B.J.
        • L’Insalata
        • Irrgang J.
        • Warner J.J.
        Comparison of arthroscopic and open anterior shoulder stabilization.
        J Bone Joint Surg Am. 2000; 82: 1108-1114
        • Caprise P.A.
        • Sekiya J.K.
        Open and arthroscopic treatment of multidirectional instability of the shoulder.
        Arthroscopy. 2006; 22: 1126-1131
        • Speer K.P.
        • Warren R.F.
        • Pagnani M.
        • Warner J.J.
        An arthroscopic technique for anterior stabilization of the shoulder with a bioabsorbable tack.
        J Bone Joint Surg Am. 1996; 78: 1801-1807
        • Bokor D.J.
        • Conboy V.B.
        • Olson C.
        Anterior instability of the glenohumeral joint with humeral avulsion of the glenohumeral ligament: A review of 41 cases.
        J Bone Joint Surg Br. 1999; 81: 93-96
        • Schippinger G.
        • Vasiu P.S.
        • Fankhauser F.
        • Clement H.G.
        HAGL lesion occurring after successful arthroscopic Bankart repair.
        Arthroscopy. 2001; 17: 206-208
        • Kim S.H.
        • Ha K.I.
        • Kim Y.M.
        Arthroscopic revision Bankart repair: A prospective outcome study.
        Arthroscopy. 2002; 15: 469-482
        • Uhurchak J.M.
        • Arciero R.A.
        • Huggard D.
        • Taylor D.C.
        Recurrent shoulder instability after open reconstruction in athletes involved in collision and contact sports.
        Am J Sports Med. 2000; 28: 794-799
        • Pagnani M.J.
        • Dome D.C.
        Surgical treatment of traumatic anterior shoulder instability in American football players.
        J Bone Joint Surg Am. 2002; 82: 711-715
        • Calandra J.J.
        • Baker C.L.
        • Uribe J.
        The incidence of Hill-Sachs lesions in initial anterior shoulder dislocations.
        Arthroscopy. 1989; 5: 254-257
        • Hovelius L.
        Anterior dislocation of the shoulder in teenagers and young adults.
        J Bone Joint Surg Am. 1987; 69: 393-399
        • Simonet W.T.
        • Cofield R.H.
        Prognosis in anterior shoulder dislocation.
        Am J Sports Med. 1984; 12: 19-24
        • Rowe C.R.
        • Patel D.
        • Southmayd W.W.
        The Bankart procedure: A long-term end-result study.
        J Bone Joint Surg Am. 1978; 60: 1-16
        • Rowe C.R.
        • Zarins B.
        • Ciullo J.V.
        Recurrent anterior dislocation of the shoulder after surgical repair.
        J Bone Joint Surg Am. 1984; 66: 159-168
        • Burkhart S.S.
        • DeBeer J.F.
        Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: Significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion.
        Arthroscopy. 2000; 16: 677-694
        • Gerber C.
        • Nyffeler R.W.
        Classification of glenohumeral joint instability.
        Clin Orthop Relat Res. 2002; : 65-76
        • Warner J.J.P.
        • Gill T.J.
        • O’Holleran J.D.
        • et al.
        Anatomical glenoid reconstruction for recurrent anterior glenohumeral instability with glenoid deficiency using an autogenous tricortical iliac crest bone graft.
        Am J Sports Med. 2006; 34: 205-212
        • Montgomery Jr, M.H.
        • Wahl M.
        • Hettrich C.
        • Itoi E.
        • Lippitt S.B.
        • Matsen III, F.A.
        Anteroinferior bone-grafting can restore stability in osseous glenoid defects.
        J Bone Joint Surg Am. 2005; 87: 1972-1977
        • Lo I.K.
        • Parten P.M.
        • Burkhart S.S.
        The inverted pear glenoid: An indicator of significant glenoid bone loss.
        Arthroscopy. 2004; 20: 169-174
        • Itoi E.
        • Lee S.B.
        • Amrami K.K.
        • Wenger D.E.
        • An K.N.
        Quantitative assessment of classic anteroinferior bony Bankart lesions by radiography and computed tomography.
        Am J Sports Med. 2003; 31: 112-118
        • Sekiya J.K.
        • Wickwire A.C.
        • Stehle J.H.
        • Debski R.E.
        Biomechanical analysis of Hill-Sachs lesions in a joint compression model: Injury and repair using articular allograft transplantation. 2006 (Presented at the Arthroscopy Association of North America Annual Meeting, May 18, Hollywood, FL.)
        • Hill H.A.
        • Sachs M.D.
        The groove defect of the humeral head.
        Radiology. 1940; 35: 690-700
        • Miniaci A.
        • Gish M.W.
        Management of anterior glenohumeral instability associated with large Hill-Sachs defects.
        Tech Shoulder Elbow Surg. 2004; 5: 170-175
        • Chapovsky B.S.
        • Kelly IV, J.D.
        Osteochondral allograft transplantation for treatment of glenohumeral instability.
        Arthroscopy. 2005; 21 (Available online at 1007.e1-1007.e4
        • Kropf E.J.
        • Sekiya J.K.
        Osteoarticular allograft transplantation for large humeral head defects in glenohumeral instability.
        Arthroscopy. 2007; 23 (Available online at 322.e1-322.e5
        • Savoie F.H.
        • Miller C.D.
        • Field F.D.
        Arthroscopic reconstruction of traumatic anterior instability of the shoulder: The Caspari technique.
        Arthroscopy. 1997; 13: 201-209
        • Mueller M.B.
        • Fredrich H.H.
        • Steinhauser E.
        • Schreiber U.
        • Arians A.
        • Imhoff A.B.
        Biomechanical evaluation of different suture anchors for the stabilization of anterior labrum lesions.
        Arthroscopy. 2005; 21: 611-619
        • Van Oostveen D.P.H.
        • Schild F.J.A.
        • Van Haeff M.J.
        • Saris D.B.F.
        Suture anchors are superior to transglenoid sutures in arthroscopic shoulder stabilization.
        Arthroscopy. 2006; 12: 1290-1297
        • Sekiya J.K.
        Arthroscopic labral repair and capsular shift of the glenohumeral joint: Technical pearls for a multiple pleated plication through a single working portal.
        Arthroscopy. 2005; 21 (Available online at 766.e1-766.e7
        • McIntyre L.F.
        • Caspari R.B.
        • Savoie III, F.H.
        The arthroscopic treatment of multidirectional shoulder instability: Two-year results of multiple suture technique.
        Arthroscopy. 1997; 13: 418-425
        • Treacy S.H.
        • Savoie III, F.H.
        • Field L.D.
        Arthroscopic treatment of multidirectional instability.
        J Shoulder Elbow Surg. 1999; 8: 345-350
        • Gartsman G.M.
        • Roddey T.S.
        • Hammerman S.M.
        Arthroscopic treatment of bidirectional glenohumeral instability: Two to five-year follow-up.
        J Shoulder Elbow Surg. 2001; 10: 28-36
        • Bigliani L.U.
        • Pollock R.G.
        • Soslowsky L.J.
        • Flatow E.L.
        • Pawluk R.J.
        • Mow V.C.
        Tensile properties of the inferior glenohumeral ligament.
        J Orthop Res. 1992; 10: 187-197
        • Mologne T.S.
        • McBride M.T.
        • Lapoint J.M.
        Assessment of failed arthroscopic anterior labral repairs.
        Am J Sports Med. 1997; 25: 813-817
        • Sekiya J.K.
        • Zehms C.T.
        Arthroscopic management of recurrent glenohumeral instability.
        Oper Tech Sports Med. 2006; 13: 189-195
        • Wolf E.M.
        • Cheng J.C.
        • Dickson K.
        Humeral avulsion of the glenohumeral ligaments as a cause of anterior shoulder instability.
        Arthroscopy. 1995; 11: 600-607
        • Kon Y.
        • Shiozaki H.
        • Sugaya H.
        Arthroscopic repair of a humeral avulsion of the glenohumeral ligament lesion.
        Arthroscopy. 2005; 21 (Available online at 632.e1-632.e6
        • Richards D.P.
        • Burkhart S.S.
        Arthroscopic humeral avulsion of the glenohumeral ligaments (HAGL) repair.
        Arthroscopy. 2004; 20: 134-141
        • Meehan R.E.
        • Petersen S.A.
        Results and factors affecting outcome of revision surgery or shoulder instability.
        J Shoulder Elbow Surg. 2005; 14: 31-37
        • Kim S.H.
        • Ha K.I.
        • Cho Y.B.
        • Ryu B.D.
        • Oh I.
        Arthroscopic anterior stabilization of the shoulder: Two to six-year follow-up.
        J Bone Joint Surg Am. 2003; 85: 1511-1518
        • Cho N.S.
        • Hwang J.C.
        • Rhee Y.G.
        Arthroscopic stabilization in anterior shoulder instability: Collision athletes versus noncollision athletes.
        Arthroscopy. 2006; 22: 947-953
        • Carreira D.S.
        • Mazzocca A.D.
        • Oryhon J.
        • Brown F.M.
        • Hayden J.K.
        • Romeo A.A.
        A prospective outcome evaluation of arthroscopic Bankart repairs: Minimum 2-year follow-up.
        Am J Sports Med. 2006; 34: 771-777
        • Mazzocca A.D.
        • Brown F.M.
        • Carreira D.S.
        • Hayden J.
        • Romeo A.A.
        Arthroscopic anterior shoulder stabilization of collision and contact athletes.
        Am J Sports Med. 2005; 33: 52-60