Larry D. Field, MD
Mississippi
Sports Medicine Center
Jackson,
Mississippi
I. Decision Making - The
decision regarding the use of an arthroscopic or open technique for shoulder
stabilization depends on many factors. Likewise, assessing the relative
advantages and disadvantages of techniques for stabilization involves a number
of important parameters.
What
does "better" mean?
- lower recurrence rate?
- less invasive?
- improved motion postoperatively?
- lower complication rate?
- technically easier?
- all of the above?
II. Goal of surgical intervention
- The best procedure for shoulder instability would result in no
postoperative recurrences, normal postoperative motion, no postoperative pain
and a return to preinjury performance levels in all patients undergoing the
intervention. Certainly, no technique currently available can satisfy these
requirements. However, critical assessment of the various open and arthroscopic
procedures now available allows for some determination of relative merit.
III. Not a black and white issue
- No single technique for shoulder stabilization is always best. Numerous
factors must be considered in the evaluation of the patient in order to
determine the best operation for that individual.
A.
Some of the factors that must be considered include:
1.
Pathology
-
Bankart lesion with healthy, robust labroligamentous tissue
vs.
-
Patulous, thin and poorly defined capsuloligamentous tissue without a Bankart
lesion
2.
Instability pattern
Anterior
vs.Posterior vs.MDI
3.
Technique
-
Open: Bankart vs. Magnuson-Stack
-
Arthroscopic: Bankart vs.Transglenoid capsulorrhaphy vs.Thermal
capsulorrhaphy
4.
Patient
- 21
year old college pitcher with dominant-sided instability
vs.
-
16 year old offensive tackle with non-dominant instability
5. Surgeon
-
Technical capabilities
500
shoulder arthroscopies per year vs.
10
shoulder arthroscopies per year
-
Tolerance for failure -What’s acceptable? 2%, 5%, 10%, 20%? The literature
is full of contradictory statements regarding the acceptability of recurrence
rates. Acceptable outcomes differ from patient to patient and surgeon to
surgeon. No widely accepted figure is available on what recurrence rate is
acceptable.
No
prospective, randomized studies exist comparing arthroscopic techniques with
open techniques. Several prospective non-randomized studies suggest increased
recurrence rates with arthroscopic techniques but also improved motion and
reduced pain. (Weber (1991) and Jorgensen (1995)) Several retrospective,
non-randomized studies have also been presented and generally suggest similar
results.
IV. Parameters for consideration
- Very few conclusions are possible when all arthroscopic procedures are
considered as a group and all open procedures are considered as well. Likewise,
bulking all instability patterns into a discussion of the efficacy of
arthroscopic vs. open techniques diminishes the value of any conclusions to be
drawn. For this reason, limiting the discussion to a specific group of
parameters will allow for more valid conclusions.
A.
The following parameters can serve as guides for consideration:
1.
Pathology
-
Traumatic, recurrent anterior dislocator with a Bankart lesion
2.
Surgical technique
-
Open Bankart (axillary incision, outpatient surgery, subscapularis split or
release)
vs.
-
Arthroscopic Bankart (suture anchors or suretacs) or transglenoid capsular
shift
3.
Patient
-
17 year old high school linebacker with 5
previous dislocations
4.
Surgeon (Your Name Here)
- Experience
- Technical abilities
- Tolerance
B.
Limiting our discussion to these parameters leaves only one variable: the
surgeon. Based on these restrictive parameters, several facts can be
stated:
I.
Recurrences less likely with open stabilization.
2.
Loss of motion less with arthroscopic techniques.
3.
Inpatient vs. outpatient? Open more likely to be admitted although open can be
routinely carried out as outpatient.
4.
Cost: Arthroscopic less only if open patient admitted (also, cost of recurrent
instability must be considered)
5.
Length of operative time (1 hour or less required regardless of technique for
experienced surgeon)
6.
Recovery time: no significant difference unless recovery of motion difficult
7.
Cosmesis: arthroscopy superior although axillary incision cosmetically pleasing
I.
Recurrence rate lower with open stabilization but motion generally better with
arthroscopic techniques (motion and stability mutually exclusive?)
2.
Neither technique is "easy".
3.
Surgical technique ultimately chosen should be based on surgeon’s experience,
technical ability with the arthroscope, specifics of the pathology including
the instability pattern, and aspirations and activity level of the patient
postoperatively.
4.
Tailor the operation to the patient and not the patient to the operation.