Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Jon J.P. Warner, MD*,
Harvard Shoulder Service, Massachusetts General Hospital, Boston, Massachusetts
Posted February 2007
In this article, the authors have performed an extensive
review of the literature on arthroscopic and open repairs for recurrent
shoulder instability. Their meta-analysis included published and unpublished
series, utilized both fixed-effects and random-effects models, carefully
analyzed for publication bias, included a number-to-treat analysis in order to
demonstrate clinical relevance, and included an analysis of effect of study
quality on the observed treatment effect. They tested the hypothesis that the
literature would demonstrate a significant difference between arthroscopic and
open repair from the standpoint of five measures of success: restoration of
stability, recurrence of instability, rate of reoperation for instability, ability
of patients to return to work and sports, and final Rowe score. Furthermore, arthroscopic
analysis was stratified into three techniques for analysis: use of suture
anchors, use of bioabsorbable tacks, and use of transglenoid sutures.
The authors clearly demonstrated that open approaches were
more reliable in restoring stability to the shoulder; however, arthroscopic
techniques resulted in a higher Rowe score. This suggests that, in a given
population of patients, range of motion may be better with arthroscopic
techniques, but at the expense of stability. Of particular interest with regard
to arthroscopic repair was the finding of a higher success rate with use of bioabsorbable
tacks than with use of sutures.
The authors have provided an insightful analysis of the
available literature, which seems to send the message that open repair for
instability is more reliable than arthroscopic repair; however, I believe that this
conclusion is probably not accurate.
Several important factors that may not be well controlled in
the literature may also be confounding variables in this analysis. First, the
use of arthroscopic techniques to repair shoulder instability is a relatively
recent development that has evolved during the last few decades, and the
learning curve for patient selection and for proper surgical technique is
clearly reflected in the literature. This may be an important reason why
failure rates seem to be higher with arthroscopic repairs. Second, the
experience with thermal capsular shrinkage as an adjunct to suture repair has
proven to be an unfortunate detour over the past five years. The failure rates
with this technique were relatively high, and this may also be a confounding
variable in the overall analysis. Third, there has been a growing understanding
about the biomechanics of shoulder stability and, therefore, the pathomechanics
of instability, especially in the presence of osseous lesions of the glenoid
and the humeral head. This distinction may be buried within studies that report
higher arthroscopic failure rates, as many surgeons, not recognizing the
relevancy of osseous lesions to shoulder stability, probably attempted an
arthroscopic Bankart repair rather than open repair in patients with relevant
osseous lesions. With use of a more informed patient selection process,
patients with such lesions can now be identified as candidates who are better
suited to an open repair, usually with resolution of the osseous abnormality as
part of the procedure.
Finally, it would seem that the literature tends to under-report
complications. For example, substantial loss of motion and its effect on the ultimate
development of arthritis in shoulders with overly tight open repairs has
clearly been demonstrated. Yet these authors did not observe this as an
important issue. In addition, subscapularis rupture after repair with open
surgery has also been described; yet their literature review did not
demonstrate this as a problem in patients who underwent open repair of instability.
I believe the best approach to the treatment of recurrent
shoulder instability lies in the use of a balanced treatment algorithm that is based
on an appreciation of the particular biomechanical factors associated with instability
in each patient. Obviously, excellent surgical technique is required for the
performance of either an open or an arthroscopic repair. The social and
economic reality is that arthroscopic repair is going to remain an important
option in the treatment of patients with shoulder instability. The great
service of this paper is to highlight the necessity for surgeons to consider the
alternative of open surgery in appropriately selected patients.
*The authors did not receive any outside funding or grants
in support of their research for or preparation of this work. Neither they nor
a member of their immediate families received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. A
commercial entity (fellowship support was received from Smith and Nephew,
Mitek, and Arthrex) paid or directed in any one year, or agreed to pay or
direct, benefits in excess of $10,000 to a research fund, foundation, division,
center, clinical practice, or other charitable or nonprofit organization with
which the authors, or a member of their immediate families, are affiliated or
associated.
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