Results And Outcomes

Over the past decade, rates of recurrent instability with nonoperative treatment following a traumatic anterior dislocation in several studies have been reported to be between 50% and 92%. The difference in reported recurrence rates is often correlated with the age of the patients at the time of the first dislocation. In a study of young Swedish hockey players, Cvitanic et al7 reported the recurrence rate with nonoperative treatment in players younger than the age of 20 to be greater than 90%. The level of activity a patient resumes after an initial shoulder dislocation may determine his or her risk for reinjury. Once recurrent instability fails nonoperative treatment and is symptomatic, an operative approach is recommended.

For recurrent instability, numerous open and arthroscopic techniques have been reported. Historically, the lowest recurrence rates have been reported with open techniques. However, most studies comparing open and arthroscopic results have included arthroscopic techniques that poorly mimicked the anatomic labral repair and capsulorrhaphy of the open procedure. The traditional open Bankart repair, however, is not an easy surgical procedure and can be complicated by neurovascu-lar injury, postoperative stiffness, and long-term glenohumeral arthritis. Arthroscopic Bankart repairs have been reported to decrease operative time, blood loss, postoperative narcotic use, and time off from work.20 The evolution of arthroscopic stabilization has progressed from glenoid abrasion to the use of various devices to repair the labral injury including arthroscopic staples4 and transglenoid labral fixation where sutures are passed across the glenoid and then tied over the posterior fascia of the shoulder.21 In 1991, Warner and Warren22 introduced a bioab-sorbable tack (Suretac, Acufex Microsurgical, Mansfield, MA) that can be inserted arthroscopically to repair Bankart lesions. The tacks eliminate the need to tie arthroscopic knots but have limited initial strength, degrade quickly, and do not effect a reduction in capsular volume. Although good results were reported in acute stabilization of first-time dislocations, the results for recurrent instability were much less promising.19,23-26 None of these techniques paralleled that which was done via an open approach.

The use of suture anchors for shoulder stabilization was first reported by Weber et al27 in 1991. Their use provides strong fixation of soft tissue to bone and allows tensioning of the antero-inferior capsulolabral complex. Metallic and bioabsorbable

Figure 18-16 A and B, Anteroposterior and axillary lateral radiographs of a shoulder with metal suture anchors (arrows) placed too far medially. The patient developed recurrent instability and required revision stabilization.

anchors with either absorbable or nonabsorbable sutures are available. A myriad of surgical instruments are available to pass and retrieve sutures for shoulder repairs. Most devices require the ability to reliably tie arthroscopic knots. Stronger suture, color-coding of each suture limb, and double-loaded anchors have been some recent advances that facilitate arthroscopic stabilization.

Several recently published studies assessing results between open and arthroscopic repairs in patients with recurrent anterior instability demonstrated comparable outcomes with both techniques.13,24,28

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