Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Arthroscopic Compared with Open Repairs for Recurrent Anterior Shoulder Instability"
by Tim R. Lenters, MD, et al.

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 Their meta-analysis included published and unpublished series, utilized both fixed-effects and random-effects models, carefully analyzed for publication bias, included a number-to-treat analysis in order to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.