The Journal of Bone and Joint Surgery (American). 2007;89:244-254.
doi:10.2106/JBJS.E.01139
© 2007 The Journal of Bone and Joint Surgery, Inc.
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Arthroscopic Compared with Open Repairs for Recurrent Anterior Shoulder Instability

A Systematic Review and Meta-Analysis of the Literature

Tim R. Lenters, MD1, Amy K. Franta, MD2, Fredric M. Wolf, PhD1, Seth S. Leopold, MD1 and Frederick A. Matsen, III, MD1

1 Department of Orthopaedics and Sports Medicine (T.R.L., S.S.L, and
F.A.M. III), Box 356500, and Department of Medical Education and Biomedical
Informatics (F.M.W.), Box 357240, University of Washington
Medical Center, 1959 N.E. Pacific Street, Seattle, WA 98195. E-mail address for F.A. Matsen: matsen{at}u.washington.edu
2 Aspen Orthopaedic and Rehabilitation, 19475 West North Avenue, Suite
201, Brookfield, WI 53045

Investigation performed at the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington

Disclosure: 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 (DePuy) paid or directed in any one year, or agreed to pay or direct, benefits of less than $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. (DePuy endowed a Chair in Shoulder Research, which is currently held by F.A. Matsen III.)

Background: Both arthroscopic and open surgical repairs are utilized for the management of anterior glenohumeral instability. To determine the evidence supporting the relative effectiveness of these two approaches, we conducted a rigorous and comprehensive analysis of all reports comparing arthroscopic and open repairs.

Methods: A systematic analysis of eighteen published or presented studies was performed to determine if there were significant differences between the two approaches with regard to recurrence (recurrent dislocation, subluxation, and/or apprehension and/or a reoperation for instability), return to work and/or sports, and Rowe scores. We also performed subgroup analysis to determine if the quality of the study or the arthroscopic technique influenced the results.

Results: We identified four randomized controlled trials, ten controlled clinical trials, and four other comparative studies. Results were influenced both by the quality of the study and by the arthroscopic technique. Meta-analysis revealed that, compared with open methods, arthroscopic repairs were associated with significantly higher risks of recurrent instability (p < 0.00001, relative risk = 2.37, 95% confidence interval = 1.66 to 3.38), recurrent dislocation (p < 0.0001, relative risk = 2.74, 95% confidence interval = 1.75 to 4.28), and a reoperation (p = 0.002, relative risk = 2.32, 95% confidence interval = 1.35 to 3.99). When considered alone, arthroscopic suture anchor techniques were associated with significantly higher risks of recurrent instability (p = 0.01, relative risk = 2.25, 95% confidence interval = 1.21 to 4.17) and recurrent dislocation (p = 0.004, relative risk = 2.57, 95% confidence interval = 1.35 to 4.92) than were open methods. Arthroscopic approaches were also less effective than open methods with regard to enabling patients to return to work and/or sports (p = 0.03, relative risk = 0.87, 95% confidence interval = 0.77 to 0.99). On the other hand, analysis of the randomized clinical trials indicated that arthroscopic repairs were associated with higher Rowe scores (p = 0.002, standardized mean difference = 0.43, 95% confidence interval = 0.16 to 0.70) than were open methods. Similarly, analysis of the arthroscopic suture anchor techniques alone showed the Rowe scores to be higher (p = 0.04, standardized mean difference = 0.29, 95% confidence interval = 0.01 to 0.56) than those associated with open methods.

Conclusions: The available evidence indicates that arthroscopic approaches are not as effective as open approaches in preventing recurrent instability or enabling patients to return to work. Arthroscopic approaches resulted in better function as reflected by the Rowe scores in the randomized clinical trials. The study design and the arthroscopic technique had substantial effects on the results of the analysis.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.


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