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Arthroscopic Bankart Repair of Anterior Detachments of the Glenoid Labrum. A Prospective Study*

DANIEL B. O'NEILL, M.D., NASSAU BAY, TEXAS

Investigation performed at St. John Sports Medicine Center, Nassau Bay

	Abstract

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Background: The purpose of this study was to evaluate the results of an arthroscopic transglenoid suture-stabilization procedure in athletically active patients who had recurrent, unilateral, unidirectional anterior dislocations of the shoulder and an isolated anterior detachment of the glenoid labrum. Methods: Forty-one patients who had unilateral, unidirectional anterior dislocations of the shoulder and an isolated anterior detachment of the glenoid labrum were managed with arthroscopic repair. All patients were athletic, and seventeen of the male patients were football players. No patient had inferior or posterior laxity or a posterior detachment. The sutures were anchored to the posterior aspect of the scapula, and the knots were tied anteriorly to secure the detached region of the labrum and the inferior glenohumeral ligament to the anterior aspect of the scapula. The mean duration of follow-up was fifty-two months (range, twenty-five months to seven years). The patients were evaluated annually with a physical examination, radiographs, isokinetic strength-testing, the modified shoulder-rating scale of Rowe and Zarins, and the scoring system of the American Shoulder and Elbow Surgeons. Results: Forty (98 percent) of the forty-one athletes returned to their preoperative sport postoperatively. Thirty-nine patients (95 percent) had no additional dislocations or subluxations, and two (5 percent), both of whom were football players, had a single episode of subluxation. Thirty-seven patients (90 percent) had a score of at least 80 points on the scale of Rowe and Zarins, and thirty-four (83 percent) had a score of at least 90 points. Thirty-nine patients (95 percent) had a score of at least 80 points on the scale of the American Shoulder and Elbow Surgeons, and twenty-five (61 percent) had a score of at least 90 points. Lower scores were associated with loose bodies seen on arthroscopy (p = 0.001), osseous lesions seen on postoperative radiographs (p = 0.036), and subluxation (p = 0.000). Twenty-two shoulders (54 percent) had a full range of motion in all planes, and eighteen (44 percent) had no strength deficit in any position on isokinetic testing. With the numbers available for study, no significant association was found between the presence of a Hill-Sachs or an osseous Bankart lesion on preoperative radiographs and the overall score on the scale of Rowe and Zarins or the scale of the American Shoulder and Elbow Surgeons; however, there was a significant association between the range of motion and an osseous Bankart lesion on preoperative radiographs (p = 0.002) and between decreased strength on isokinetic testing and a Hill-Sachs lesion on preoperative radiographs and an osseous lesion on postoperative radiographs (p = 0.022). There also was a significant association between a decreased range of motion (p < 0.002) and decreased strength (p = 0.014) and the arthroscopic finding of loose bodies. Muscle strength also was affected by arm dominance and the number of preoperative dislocations. Conclusions: Arthroscopic transglenoid repair of isolated anterior labral detachments restored stability of the shoulder and led to a favorable outcome in thirty-nine (95 percent) of the forty-one athletes. Only the two football players who had postoperative subluxation had a score of less than 80 points according to the scale of the American Shoulder and Elbow Surgeons.

	Introduction

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Operative techniques for the treatment of recurrent anterior dislocations of the shoulder ideally achieve stability without loss of mobility and strength^{1,7,10,11,25,32}. Satisfactory stabilization has been accomplished with open anterior capsulolabral reconstructions such as the Bankart procedure^5,32 and its modifications^1,25,36. However, difficulty in achieving strength and in returning to athletic activities^25,31 as well as a decreased range of motion^8,18 following open Bankart procedures has led to the development of arthroscopic stabilization techniques^{2-4,10,12-14,16,19,20,24-26,34,35,37}.

Stability of the shoulder has varied widely after arthroscopic procedures, and technical complications and anatomical limitations have narrowed the indications for arthroscopic stabilization^{4,7,10,15,17,19-24,26-28,34,35,37}.

The purpose of this prospective study was to assess the outcomes of a standardized arthroscopic transglenoid suture-stabilization technique for the treatment of recurrent unidirectional anterior dislocations of the shoulder and an isolated anterior detachment of the glenoid labrum in athletically active patients.

	Materials and Methods

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Sixty-three patients with documented unilateral anterior dislocations of the shoulder were managed, between April 1991 and May 1996, with a closed reduction in an emergency department or by an on-field physician or licensed athletic trainer. Fifty patients (79 percent) who had not had any previous physical therapy to strengthen the scapulothoracic muscles and the glenohumeral rotators were enrolled in a formal outpatient physical therapy program.

Fifty-five patients who had had at least one additional dislocation either during or after six weeks of physical therapy were offered operative treatment. Patients who had recurrent subluxations without recurrent dislocations, had bilateral instability, or had had a previous operation on the shoulder were not included in the study.

The patients were informed that they would be candidates for arthroscopic stabilization if examination under anesthesia confirmed isolated anterior glenohumeral instability and if arthroscopy revealed an isolated anterior detachment of the glenoid labrum. Furthermore, they were told that open stabilization procedures have been reported to be effective in maintaining stability in 95 percent of patients^11,32 but that such a procedure might lead to a decreased range of motion and impaired function in throwing athletes^{8,18,25,31,32}. They also were advised that arthroscopic procedures might be associated with a higher rate of failure^{12,14,16,22-24,27,28,37} but a lower prevalence of postoperative pain and incisional complications¹³ as well as less postoperative stiffness^10,26,35. The patients were given information about the prevalence of injury of the axillary nerve^5,11,18,32 associated with the open anterior procedure and about injury of the suprascapular nerve associated with arthroscopic stabilization^23,28,37.

Fifty patients who had had at least two documented episodes of anterior unilateral dislocation of the shoulder and had had failure of six weeks of formal physical therapy consented to be included in this study. All patients were examined under anesthesia. During the examination, anterior dislocation was demonstrated and attempts were made to dislocate the shoulder posteriorly and inferiorly. One patient also was found to have posterior and inferior subluxation, and another had anterior and inferior subluxation. Both patients were excluded from the study.

Arthroscopy revealed an attenuated but intact or anatomically stable anterior aspect of the glenoid labrum without detachment in four patients. These patients also were excluded from the study as it was believed that they had either capsular laxity or multidirectional instability.

The remaining forty-four patients had arthroscopic repair of the anterior aspect of the glenoid labrum between June 1991 and May 1996. Two patients were lost to follow-up, and a seventeen-year-old girl with a stable shoulder was severely hemiparetic on the side of the operation secondary to a brain injury sustained in a motor-vehicle accident. After exclusion of these three patients, the study group comprised forty-one patients, who were followed for twenty-five months to seven years (mean, fifty-two months). There were ten female patients, who had a mean age of twenty-seven years (range, seventeen to forty-nine years), and thirty-one male patients, who had a mean age of eighteen years (range, fifteen to forty-three years).

All patients participated in sports activities, but their performance was limited by the instability of the shoulder. All patients wanted to return to athletic activities. Seventeen male patients (41 percent) were football players. Twenty-five patients (61 percent) had involvement of the right shoulder, and twenty-seven (66 percent) had involvement of the dominant arm.

All patients had had at least two documented anterior dislocations (range, two to more than ten episodes; mean, three episodes). The arthroscopic anterior stabilization was performed at a mean of ten months (range, two to 144 months) after the initial dislocation.

Preoperative anteroposterior and axillary lateral radiographs of the shoulder revealed a Hill-Sachs lesion in eighteen patients (44 percent); two of these patients also had a radiographically demonstrable osseous Bankart lesion, and one also had a loose body. Another patient had an osseous Bankart lesion without a Hill-Sachs lesion. Thus, a total of nineteen patients (46 percent) had abnormal radiographic findings preoperatively. No magnetic resonance or arthrographic imaging studies were done preoperatively as no patient had findings on physical examination that suggested impingement or a rotator cuff lesion.

Operative Technique
I performed all of the procedures. The patient is placed in the beach-chair position in the operating room. After examination under anesthesia, a standard posterolateral glenohumeral portal is used to inspect the joint. The anterior portal is made lateral to the coracoid process, under arthroscopic visualization. The working portal is anterior, and the viewing portal is posterior. The anterior aspect of the scapular neck is denuded, and the bone is abraded with an arthroscopic burr. The detached anterior part of the glenoid labrum and the associated inferior glenohumeral ligament are grasped with a cannulated arthroscopic grasper (Arthrex, Winooski, Vermont), and the labrum is advanced superiorly to the abraded scapular neck (Fig. 1-A). A Beath pin then is drilled from anterior to posterior through the cannulated grasping instrument, exiting inferior to the scapular spine. A nonabsorbable braided suture is threaded anteriorly through the eyelet of the Beath pin, and the pin is grasped posteriorly through a three to four-millimeter stab incision through the skin. Before the pin and the suture are advanced across the posterior aspect of the scapula, a hemostat is used to bluntly separate the tissues from the pin posteriorly, from the superficial stab incision down to the posterior aspect of the scapula, thus ensuring posterior advancement of the knots to the bone without entrapment of muscles or nerves.

View larger version (40K): [in this window] [in a new window]   Figs. 1-A and 1-B: Schematic drawings showing the operative technique. Fig. 1-A: After the anterior aspect of the scapular neck has been abraded, the anteriorly detached labrum and the associated inferior glenohumeral ligament are grasped and advanced superiorly to the prepared bone surface. With the labral-ligament complex in the desired position, a Beath pin is drilled through the cannulated grasper instrument, across the scapula, and is retrieved posteriorly through a stab incision.

After the second transglenoid suture has been placed and secured posteriorly, the intra-articular knot-pusher (Arthrex) is used to advance extra-articular single-throw knots to secure the capsulolabral complex to the anterior aspect of the scapular neck (Fig. 1-B). The intra-articular anterior knots are secured with the shoulder in internal rotation. Five throws are made, and an arthroscopic suture-cutter is used to cut short the free suture ends. The subsequent pairs of sutures are placed at least five millimeters from the first knot. A third suture is not tied into a previous pair with this technique. A minimum of four sutures (two anterior securing knots) were used in all patients, and six sutures (three anterior knots) were used in fourteen patients (34 percent). In four of these fourteen patients, a previously placed suture was cut by the Beath pin and had to be replaced. No sutures were cut when four sutures were used.

View larger version (56K): [in this window] [in a new window]   Fig. 1-B The transcapular suture passed through the Beath pin is knotted posteriorly and advanced to the posterior aspect of the scapular neck. After the second suture has been passed superior to the first suture and secured posteriorly, anterior extra-articular single knots are made and are advanced intra-articularly through the arthroscopic knot-pusher. (Five knots are made.)

Arthroscopic Findings (Table I)
All forty-one patients had an anterior detachment of the glenoid labrum. Eight patients (20 percent) had a complex tear with separation of the labrum into superior and inferior portions. Seven patients (17 percent) had glenohumeral loose bodies, which were removed. All three radiographically visible osseous Bankart lesions were confirmed, and an additional three osseous Bankart lesions were detected, for a total of six osseous Bankart lesions (15 percent).

Postoperative Regimen
The shoulder was immobilized in a sling and swathe in internal rotation for four weeks. During this period, the patients were allowed to flex the shoulder in order to wash the axilla, but they were warned specifically against external rotation.

After the fourth postoperative week, full active forward elevation was encouraged and was assisted with physical therapy. After six weeks, internal and external rotation exercises were initiated with use of five and ten-pound (2.3 and 4.5-kilogram) weights and resistance tubing. At three months, unrestricted weight-lifting, including incline and bench-pressing, was allowed, and twenty patients (49 percent) were permitted to return to athletic activity. Throwing athletes were not allowed to throw competitively with use of the arm on the operatively stabilized side for six months. Football players were encouraged to wear a brace to limit abduction and external rotation in the first year after return to their collision sport. Patients who did not have a symmetrical range of motion were allowed to return to their sport six months after the operation.

The patients subsequently were evaluated on an annual basis. At each evaluation, the patients completed the subjective questionnaires of the modified shoulder-rating scale of Rowe and Zarins^30,32,33 and of the American Shoulder and Elbow Surgeons scoring system²⁹ (Tables II and III, respectively). Anteroposterior and axillary lateral radiographs of the shoulder were made, and the range of motion of the shoulder with the elbow at the side and the arm abducted 90 degrees was measured with a goniometer by a physical therapist. Flexion, extension, abduction, and total elevation of the shoulder girdle also were measured. Isokinetic open-chain studies of peak torque, generated with the shoulder in external and internal rotation and in 90 degrees of abduction and measured in foot-pounds (one foot-pound equals 1.356 newton-meters), were performed with use of an isokinetic dynamometer (Lido, West Sacramento, California) at velocities of sixty, 180, and 240 degrees per second.

Statistical Analysis
Performance measures were assessed with analysis of variance, and the level of significance was set at p 0.05.

	Results

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Forty (98 percent) of the forty-one patients were able to return to their sport postoperatively. Sixteen of the seventeen football players and all four throwing athletes (three baseball pitchers and one football quarterback) returned to their sport. All three baseball pitchers returned to their collegiate starting rotations, and all were pitching professionally in the minor leagues at the time of this writing. The football quarterback, however, returned for his senior year of high-school football as the second-string quarterback and the starting strong safety.

Arm dominance had no effect on return to sports activity; the only football player who did not return to his sport had operative treatment of the shoulder on the nondominant side. With the numbers available, we detected no significant difference in the outcome, as measured by the functional shoulder scores, related to whether the left or right shoulder was involved, whether the shoulder on the dominant or nondominant side needed stabilization, the patient's age or gender, the duration of follow-up, the number of dislocations before operative stabilization, or the interval between the initial dislocation and the operative reconstruction.

Dislocations and Subluxations
There were no postoperative dislocations in this series. Two patients (5 percent), both of whom were football players, had a single episode of subluxation that did not limit participation in their sport. With the numbers available, return to football was not found to significantly affect the outcome.

Compliance
Thirty-two patients (78 percent) completed the entire postoperative four-week program of immobilization and the subsequent eight-week motion and strengthening program; however, with the numbers available, compliance was not found to be significantly related to function, return to the preinjury level of athletic activity, or postoperative instability. Two patients (5 percent) did not comply with the immobilization regimen, three (7 percent) did not participate in motion and strengthening exercises, and four (10 percent) did not comply with the immobilization regimen or the rehabilitation program.

Osseous Bankart and Hill-Sachs Lesions
Neither the preoperative radiographic finding of a Hill-Sachs lesion nor a radiographically or arthroscopically identifiable osseous Bankart lesion was found to significantly affect the outcome, with the numbers available.

Arthroscopic Findings
The presence of a posterior labral tear without detachment in two patients (5 percent) was not found to significantly affect the outcome; both patients had an excellent result. A complex labral tear with separation of the detached anterior aspect of the glenoid labrum into superior and inferior portions tended to be associated with a less successful outcome, but this finding was not found to be significant. Loose bodies, found in seven patients (17 percent), were associated with a poorer score (p = 0.001).

Complications
There were two complications in two patients (5 percent). A posterior suture abscess was noted in the left, nondominant shoulder of a seventeen-year-old male football player one year postoperatively. The patient had a reoperation consisting of removal of the foreign body and irrigation and débridement, and the shoulder healed without instability. This was the only patient in the study who did not return to his sport.

A thirty-four-year-old male cyclist had sterile posterior foreign-body granulomas, and the granulomas and the foreign bodies were excised sixteen months postoperatively. The shoulder healed in a stable position, and the patient returned to his sport.

There were no other reoperations in this series. The two football players who had had a single episode of subluxation had no subsequent episodes of instability, and no operative intervention was planned.

Postoperative Radiographs
Five patients (12 percent) had radiographic changes at the time of the latest follow-up. A thirty-five-year-old female competitive horseback rider had an osteophyte in the posterior aspect of the glenoid seven years postoperatively (Fig. 2). A seventeen-year-old male baseball catcher had an osseous fragment in the inferior aspect of the capsule sixty-two months postoperatively (Fig. 3). Two patients had osteophytes on the inferior aspect of the humeral head (Fig. 4), and one patient had osteophytes on the inferior aspect of both the humeral head and the glenoid. There was a significant relationship between these radiographic findings and a less satisfactory outcome (p = 0.036).

View larger version (102K): [in this window] [in a new window]   Fig. 2 Axillary lateral radiograph of the right, dominant shoulder of a thirty-five-year-old female competitive horseback rider, made seven years postoperatively, showing an asymptomatic osteophyte (arrow) in the posterior aspect of the glenoid. The patient had a score of 100 points on the scales of both Rowe and Zarins33 and the American Shoulder and Elbow Surgeons29.

View larger version (118K): [in this window] [in a new window]   Fig. 3 Anteroposterior radiograph of the right, dominant shoulder of a seventeen-year-old male baseball catcher, made sixty-two months postoperatively, showing an osseous fragment (arrow) in the inferior aspect of the capsule. The patient was playing National Collegiate Athletic Association Division-II baseball, and he reported some pain after long periods of throwing. He had a score of 95 points on the scale of Rowe and Zarins33 and a score of 86 points on the scale of the American Shoulder and Elbow Surgeons29.

View larger version (131K): [in this window] [in a new window]   Fig. 4 Anteroposterior radiograph of the left, nondominant shoulder of a twenty-one-year-old male football player (National Collegiate Athletic Association Division II), made fifty-four months postoperatively. An osteophyte (arrow) is visible on the inferior aspect of the humeral head. The patient continued to play college football, without wearing a brace for stabilization, for three years after a single episode of subluxation. He did not comply with the postoperative immobilization regimen or the muscle-strengthening rehabilitation program. He had a score of 55 points on the scale of Rowe and Zarins33 and a score of 71 points on the scale of the American Shoulder and Elbow Surgeons29.

Functional Testing
According to the modified shoulder scale of Rowe and Zarins³³, thirty-four patients (83 percent) had a score of at least 90 points, and thirty-seven (90 percent) had a score of at least 80 points (Table IV). In the current study, a score of 90 to 100 points indicates an excellent result and 70 to 89 points, a good result, which is more stringent than the scale of Rowe and Zarins. The scores ranged from 55 to 100 points. Four patients (10 percent) had a score of less than 80 points, and the two football players who had had an episode of subluxation each had a score of 55 points.

Range of Motion
Twenty-two patients (54 percent) had a full range of motion in all planes at the time of the latest follow-up examination. Four patients (10 percent) lacked 2 to 15 degrees (mean, 4 degrees) of flexion, five patients (12 percent) lacked 2 to 10 degrees (mean, 5 degrees) of total elevation of the shoulder girdle, six patients (15 percent) lacked 2 to 30 degrees (mean, 7 degrees) of abduction, and six lacked 2 to 15 degrees (mean, 4 degrees) of extension. Eight patients (20 percent) lacked 2 to 25 degrees (mean, 12 degrees) of external rotation with the elbow at the side, and nine (22 percent) lacked 5 to 51 degrees (mean, 9 degrees) of external rotation with the shoulder abducted 90 degrees. Six of the latter nine patients also lacked external rotation with the elbow at the side. Eleven patients (27 percent) could not internally rotate the shoulder enough to touch the same spinous-process level as they could touch with the thumb of the uninvolved extremity; the difference in internal rotation between the two sides ranged from one to four levels (mean, two levels). Nine (22 percent) of the patients lacked 1 to 28 degrees (mean, 5 degrees) of internal rotation with the shoulder abducted 90 degrees.

Forward elevation of the glenohumeral joint varied significantly according to the time until the operation (p = 0.027), the presence of an osseous Bankart lesion on preoperative radiographs (p = 0.002), and the arthroscopic finding of loose bodies (p = 0.001). Total elevation of the shoulder girdle varied significantly according to the time until the operation (p = 0.014), the presence of an osseous Bankart lesion on preoperative radiographs (p = 0.001), and the arthroscopic finding of loose bodies (p = 0.002). Abduction was significantly affected by the finding of an osseous Bankart lesion on preoperative radiographs and the arthroscopic finding of loose bodies (p = 0.019 for both).

External rotation with the elbow at the side varied significantly on the basis of the patient's age (p = 0.036) and the arthroscopic finding of a posterior labral tear (p = 0.001). External rotation with the shoulder abducted 90 degrees varied significantly according to whether loose bodies were identified arthroscopically (p = 0.014). No relationship was detected, with the numbers available, between the spinous-process level that the patient could touch on internal rotation and any variable; however, internal rotation with the shoulder abducted 90 degrees varied significantly according to the presence of an osseous Bankart lesion on preoperative radiographs (p = 0.008) and the arthroscopic finding of loose bodies (p = 0.038).

Isokinetic Testing
Eighteen patients (44 percent) had no strength deficits in any position of the shoulder on isokinetic testing at the time of the latest follow-up examination. Open-chain testing with the shoulder in external rotation and 90 degrees of abduction revealed peak torque deficits in seventeen patients (41 percent) at 60 degrees per second compared with the value for the contralateral side; the deficits ranged from 4 to 48 percent, with a mean of 17 percent. Fourteen patients (34 percent) had deficits at 180 degrees per second, with the deficits ranging from 6 to 45 percent (mean, 25 percent), and sixteen patients (39 percent) had deficits at 240 degrees per second, with the deficits ranging from 7 to 40 percent (mean, 16 percent). Twelve patients (29 percent), six of whom had involvement of the shoulder on the dominant side, lacked strength in external rotation at all speeds.

Eleven patients (27 percent) had internal rotation deficits at 60 degrees per second, with the deficits ranging from 2 to 26 percent (mean, 18 percent). Ten patients (24 percent) had such deficits at 180 degrees per second, with the deficits ranging from 7 to 52 percent (mean, 17 percent). Six patients (15 percent) had deficits at 240 degrees per second, with the deficits ranging from 4 to 55 percent (mean, 28 percent). Five patients (12 percent) had internal rotation deficits at all speeds; four of these five patients had involvement of the nondominant side.

Four patients (10 percent) had deficits in external and internal rotation in the nondominant shoulder at all speeds that were tested.

External rotation at 60 degrees per second varied significantly in association with the number of dislocations (p = 0.044) and involvement of the left side (p = 0.010). At 180 degrees per second, significant variables included the number of dislocations (p = 0.021), a Hill-Sachs lesion on preoperative radiographs (p = 0.022), and an osseous lesion on postoperative radiographs (p = 0.038). At 240 degrees per second, significant variables included the number of dislocations (p = 0.021), involvement of the dominant side (p = 0.026), a Hill-Sachs lesion (p = 0.035), a complex labral tear (p = 0.004), loose bodies (p = 0.043), and an osseous lesion on postoperative radiographs (p = 0.016).

Internal rotation deficits varied significantly at 60 and 180 degrees per second in association with involvement of the left side (p = 0.027 and 0.015, respectively) and involvement of the dominant side (p = 0.013 and 0.015, respectively). Significant variables at 240 degrees per second included the time until the operation (p = 0.029), involvement of the left side (p = 0.017), and involvement of the dominant side (p = 0.009).

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
In the current study, arthroscopic transglenoid suture stabilization for the treatment of isolated anterior labral detachments restored stability of the shoulder in thirty-nine (95 percent) of forty-one athletes who had unilateral traumatic anterior dislocations. According to the scale of Rowe and Zarins³³, four patients (10 percent) had a less-than-good result (a score of less than 80 points); these included the two football players who had had an episode of subluxation and two patients who had good stability but had pain with activities. According to the scale of the American Shoulder and Elbow Surgeons²⁹, only the two football players (5 percent) who had had an episode of subluxation had a less-than-good result (a score of less than 80 points). Therefore, whereas 90 percent of the patients had a good or excellent result and 83 percent had an excellent result according to the scale of Rowe and Zarins, 95 percent had a good or excellent result (a score of at least 80 points) and 61 percent had an excellent result (a score of at least 90 points) on the American Shoulder and Elbow Surgeons scale. Both systems have weaknesses; while it is harder to achieve an excellent result on the American Shoulder and Elbow Surgeons scale, that system can be less discriminating between poor and fair results^6,30.

While participation in a physiotherapy program was used as a preoperative criterion for all patients in this study, it has not proved to be successful for most young patients who have traumatic anterior dislocations⁹. Fifty (79 percent) of the sixty-three patients who initially were examined needed operative treatment despite physiotherapy.

Most failures of arthroscopic transglenoid suture techniques that have been reported in the literature have been associated with tying of the sutures posteriorly over the infraspinatus fascia^{12,14,21,22,28,35,37}. Pagnani et al.²⁸ reported that most of these failures occurred in the initial two years after the procedure, and other authors^22,23,35 have reported increased rates of failure in association with an age of less than twenty-five years, osseous Bankart lesions, and participation in collision sports such as football. Tying of the sutures over posterior soft tissue does not allow for consistent tensioning of the anterior aspect of the labrum to the anterior aspect of the scapular neck, as sutures can become less taut with muscle necrosis and atrophy and the rate of suprascapular nerve entrapment is greater^10,17,23. Laboratory studies have shown that the most favorable fixation is achieved when transglenoid sutures are anchored to bone posteriorly with no intervening soft tissue¹⁹.

The arthroscopic stabilization procedure that was used in our series was a modification of the techniques described by Maki²⁰ and by Morgan²⁷. Maki advanced posterior knots to the posterior aspect of the scapula to avoid tying over the infraspinatus fascia and injuring the suprascapular nerve. He reported success in fourteen of fifteen patients, but all had been followed for less than two years. Morgan reported a 5 percent rate of recurrence (nine of 175 patients) after one to seven years of follow-up. The rate of recurrence in athletes engaged in collision sports during the same interval was 17 percent (seven of forty-two). Morgan did not recommend the procedure for patients who wanted to return to collision sports.

The technique used in the current study differed from those of Maki²⁰ and Morgan²⁷. First, patients who did not have an anterior labral detachment were not included in our study. Second, four individual sutures were placed in twenty-seven (66 percent) of our patients and six individual sutures, in fourteen (34 percent).

The two complications (a suture abscess in one patient and sterile granulomas in another patient) in the current series were related to the posterior knots tied to the scapula, but there were no suprascapular nerve injuries.

Arthroscopic techniques involving the use of absorbable tacks and screws have been associated with rates of success ranging from 79 percent (with eleven failures in fifty-two patients)³⁴ to 96 percent (with one subluxation in twenty-six patients)^2,3. Anteriorly placed suture anchors have been associated with rates of success ranging from 93 percent (thirty-seven of forty)⁴ in athletes to only 70 percent (nineteen of twenty-seven, with failure being associated with more than five preoperative dislocations)¹⁶. Failure of such techniques is thought to be secondary to failure to address capsular laxity and Bankart lesions^14,34.

In the present series, even patients who had a successful outcome had a decrease in the range of motion and strength. There are no available studies, to my knowledge, of similar arthroscopic procedures or open capsulolabral reconstructions with which to compare deficits in motion and strength as measured in the current arthroscopic study. In the current series, the range of motion was significantly related to radiographically visible lesions both preoperatively and postoperatively and to the arthroscopic finding of loose bodies. Loose bodies may indicate greater trauma at the time of the dislocation or further progression of joint degeneration. The results of isokinetic strength-testing with use of the dynamometer were significantly affected by arm dominance, the preoperative and postoperative radiographic findings, the arthroscopic finding of loose bodies, and the number of preoperative dislocations.

The overall function of the shoulder, as assessed with the scale of Rowe and Zarins³³ and that of the American Shoulder and Elbow Surgeons²⁹, was significantly affected by the arthroscopic finding of loose bodies (p = 0.001) and by the postoperative radiographic findings (p = 0.036). Complex labral tears tended to be associated with lower scores, but this finding was not found to be significant, with the numbers available. The most significant factor associated with the low scores was subluxation (p = 0.000).

In summary, arthroscopic transglenoid suture stabilization can be successful in carefully selected patients who have recurrent unidirectional anterior dislocations of the shoulder with an isolated anterior detachment of the glenoid labrum. The deformation of the capsule and the ligamentous complex in an isolated anterior plane can be decreased with use of superior advancement of the detached labrum and the inferior glenohumeral ligament, followed by a four-week period of immobilization. Thus, all twenty-four athletes who did not play football and fourteen of the seventeen football players in the current series returned to their sport without shoulder instability. Two football players had a single episode of subluxation but continued to participate in their sport without additional episodes of instability or the need for a reoperation. The only collision sport represented in this series was football. Football continues to expose the repaired labrum and the capsuloligamentous complex to substantial acute destabilizing forces. Therefore, football players must be warned about the greater probability of instability on returning to their sport after an arthroscopic procedure.

NOTE: The author thanks William G. Cimino, M.D., for help in the preparation of the manuscript and Conor O'Neill for help in the collection of the data.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was Texas Joint Products, Houston, Texas.

St. John Sports Medicine Center, 18100 St. John Drive, Suite 300, Nassau Bay, Texas 77058.

	References

Top Abstract Introduction Materials and Methods Results Discussion References

 

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