Arthroscopic Stabilization for First-Time Versus Recurrent
Shoulder Instability
Robert C. Grumet, M.D., Bernard R. Bach Jr, M.D.,
and CDR Matthew T. Provencher, M.D., MC, USN
Purpose: The purpose of this study was to systematically review the evidence on the outcomes of arthroscopic repair for anterior shoulder instability in first-time dislocators when compared with patients with recurrent instability. Methods: We designed a systematic review with a specific methodology to investigate the outcomes of surgery for those with only a first-time dislocation versus those who underwent surgery after multiple instability events. We performed a literature search from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials. Key words included the following: first time, primary shoulder, or recurrent shoulder instability, shoulder dislocation, Bankart repair, arthroscopic Bankart repair, and labral repair. The inclusion criteria were cohort studies (Level I to II) that evaluated the outcomes of patients undergoing arthroscopic stabilization after the first dislocation or multiple recurrent episodes. Studies that lacked a comparison group or were retrospective (Level III studies or higher) were excluded. Results: There were 15 studies that met the inclusion criteria and were included in the final analysis: 5 in the first-time dislocation group and 10 in the recurrent instability group. Study design, patient demographics, mean number of dislocations, surgical technique, and rehabilitation proto-col, as well as subjective and objective outcome measures, were recorded. Conclusions: There were no differences in recurrence or complication rate among patients undergoing surgery after the primary dislocation when compared with those undergoing surgery after multiple recurrent episodes. Clinical outcome measures significantly improved within all independent studies from preoperatively to postop-eratively. However, because of variation in the outcome measurement tools used, no direct comparison between the study groups could be performed. Additional randomized controlled studies are needed to compare the functional outcome, quality of life, and ability to return to preinjury activity level among patients undergoing early versus delayed repair for anterior shoulder instability. Level of Evidence: Level II, systematic review of Level I and II studies.
A
nterior shoulder instability has been reported to occur in 2% to 8% of the population, most often as a result of trauma to the affected extremity. Several studies have found significant deficits in shoulder function and recurrent episodes of insta-bility after the initial dislocation, particularly in younger patients.1The rate of recurrent episodes ofinstability is dependent on the patient’s age and activity level at the time of primary dislocation, with male patients at a higher risk than female patients.1,2Robinson et al.1evaluated a prospective
cohort of patients aged between 15 and 35 years with anterior shoulder instability. They found that 56% of the patients had recurrent shoulder instabil-ity at a mean of 13 months. The highest-risk pa-tients were found to be male papa-tients, aged 20 years or younger, with a recurrence rate of 72% to 86%.
From the Division of Sports Medicine, Department of Orthope-dic Surgery, Rush University MeOrthope-dical Center (R.C.G., B.R.B.), Chicago, Illinois, and Department of Orthopedic Surgery, Naval Medical Center (M.T.P.), San Diego, California, U.S.A.
The authors report no conflict of interest. Received May 8, 2009; accepted June 11, 2009.
Address correspondence and reprint requests to CDR Matthew T. Provencher, M.D., MC, USN, Associate Professor of Surgery, USUHS, Department of Orthopaedic Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Dr, Suite 112, San Diego, CA 92134-1112, U.S.A. E-mail:mattprovencher@earthlink.net
© 2010 by the Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
0749-8063/10/2602-9254$36.00/0 doi:10.1016/j.arthro.2009.06.006
Note: To access the video accompanying this report, visit the February issue of Arthroscopy atwww.arthroscopyjournal.org.
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Other authors have found similar rates of recurrent instability (RI) in this young, active patient popu-lation.2
Because of the high rate of recurrence in this pop-ulation of patients, many authors have begun advocat-ing early surgical intervention for these “at-risk” pa-tients. Consequently, several studies have evaluated the recurrence rates and outcomes of surgical versus nonsurgical management in cases of first-time (FT) dislocation.3-7 These authors, as well as
evidence-based medicine,8 support early surgical intervention
for young male patients because of the high incidence of recurrent dislocation. Advocates for early interven-tion contend that these patients benefit from surgery because of a dramatically lower recurrence rate when compared with conservative measures. One may also deduce that early intervention allows for a more ana-tomic repair with “good” tissue, whereas patients with multiple episodes of instability may have attenuation of the anterior structures, making repair more difficult and tenuous at the time of surgery. Finally, authors argue that patients may have an improved quality of life with a more rapid return to preinjury activity level and a lower risk of recurrent episodes.
Open anterior stabilization has been considered the gold standard in the management of the young, active patient with recurrent shoulder instability. By restor-ing the anatomy of the anterior labrum and capsule to the anterior glenoid, authors have reported a recur-rence rate of 3% with the open procedure.9With the
birth of arthroscopic techniques, early attempts to repair the essential lesion of anterior shoulder insta-bility arthroscopically met with inferior results and a recurrence rate of up to 49%.10However, through the
advancement of arthroscopic techniques and a further understanding of the underlying pathoanatomy, ar-throscopic labral repair has now proven to be as suc-cessful as previous open procedures for recurrent shoulder instability.11-17
To date, there have been no prospective randomized trials comparing the results of arthroscopic labral re-pair in patients with FT dislocation versus those with RI. As a result, we devised a systematic review with defined methodology to collect the most relevant in-formation to answer a specific scientific question. The purpose of this systematic review was to critically evaluate the recurrence rate, functional outcome, and quality of life of patients undergoing surgery after the primary dislocation compared with those with multi-ple episodes. Our hypothesis is that, among a group of patients with similar demographics undergoing a com-parable operative technique and rehabilitation
proto-col, there would be no difference in recurrence rate, functional outcome, or complications between the pri-mary dislocation and multiple episode patients.
METHODS
The objective of this review was to compare the outcomes of patients with anterior shoulder instability undergoing arthroscopic stabilization after FT dislo-cation versus those undergoing surgery after multiple RI events. The inclusion criteria for studies in this review were prospective cohort studies with Level I or II evidence that evaluated patients after arthroscopic labral repair for shoulder instability. Any study that lacked a control group (therefore case series) and any retrospective review (Level III studies or higher) was excluded. Any study that could not be translated into the English language or was not in a peer-reviewed journal was also excluded. Patient demographic infor-mation, associated pathology, operative technique, ob-jective and subob-jective outcome measurements, and complications were abstracted from the studies.
Literature Search
We performed a search of all published literature from January 1966 to December 2008 using Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials. Key words included the follow-ing: first time, primary shoulder, or recurrent shoulder instability, shoulder dislocation, Bankart repair, ar-throscopic Bankart repair, and labral repair. General search terms were chosen to prevent bias and inadver-tent exclusion of poinadver-tential studies.18Studies that were
only presented as abstracts were not included in the final analysis. The references of all relevant articles and review articles were manually cross-referenced to ensure that all possible articles were considered.
Data Acquisition
Study design, patient demographics, mean number of dislocations, surgical technique, rehabilitation pro-tocol, and subjective and objective outcome measures were recorded for all studies that met the inclusion criteria. Particular attention was paid to the arthro-scopic technique, including the repair type (transgle-noid, anchors, and so on), number of implants used, and associated pathology found at the time of surgery. When possible, the percentage of satisfied or very satisfied patients in each group was collected. In ad-dition, preoperative and postoperative objective data,
including range of motion, strength, clinical out-come scales (Single Assessment Numeric Evalua-tion; Rowe; Constant; Western Ontario Shoulder Instability Index [WOSI]; Simple Shoulder Test; Dis-abilities of the Arm, Shoulder and Hand; University of California, Los Angeles; American Shoulder and El-bow Surgeons; Oxford Instability Shoulder Score; visual analog scale; and Short Form 12 Questionnaire Physical Score and Mental Score), patient satisfaction, and complications, were extracted. The data are pre-sented in table format (see “Results” section). De-scriptive statistics were provided; however, statistical comparisons were not performed.
RESULTS Literature Search
There were 3,038 articles that were in the English language and met the initial search criteria mentioned
previously. The abstracts of these studies were then re-viewed to evaluate the suitability of each study to meet the inclusion and exclusion parameters. There were 17 studies that met the inclusion criteria: 6 in the FT insta-bility treatment group and 11 in the RI group. One article from the FT instability group was excluded because the surgical group was treated with an open rather than arthroscopic repair.19One article from the RI group was
excluded because the article did not mention the number of recurrent episodes in instability patients before surgi-cal repair.20There were 15 studies that were included in
the final analysis: 5 evaluating arthroscopic repair in FT dislocation3-7 and 10 evaluating arthroscopic repair in
patients with RI.11-13,15,16,21-25 Patient Demographics
The study design, level of evidence, number of patients enrolled, follow-up, patient age, duration of symptoms, and number of episodes of instability were
TABLE1. Study and Patient Demographics
Source Study Level of Evidence Total No. of Shoulders No. of Shoulders Evaluated Effective Follow-up Dominant Mean Age at Surgery (yr) Mean Follow-up (mo) % of Male Patients Collision Sport (%) Symptom Duration (mo) Mean No. of Episodes Mean Time to Surgery (d) FT Arciero et al.,3 1994 Pro, NR II 21 21 100% 43% 20.5 32 N/R 43% N/A 1 5.5 Bottoni et al.,4 2002 Pro, R I 10 9 90% 40% 21.6 35 100% 70% N/A 1 ⬍10 Kirkley et al.,5 1999 Pro, R I 19 19 100% 47% 22.1 31.7 84% N/R N/A 1 N/R Kirkley et al.,6 2005 Pro, R I 19 16 84% 44% 22.1 79 81% N/R N/A 1 N/R Robinson et
al.,72008 Pro, R I 43 36 84% 44% 24.3 24 93% N/R N/A 1 7.6
RI Bottoni et
al.,112006 Pro, R I 32 32 100% 44% 25.2 28.5 97% N/R 35.1 Multiple
Cole et al.,12 2000 Pro, NR II 39 37 95% 49% 28 52 89% 57% 35 Multiple Fabbriciani et al.,132004 Pro, R I 30 30 100% 73% 24.5 24 80% N/R 25.3 3.2 Jorgensen et al.,151999 Pro, R I 21 21 100% 24% 28 36.2 71% N/R 51 3 to 32 Karlsson et al.,162001 Pro, NR II 60 N/R N/R N/R 26 28 75% N/R 31 6 Kartus et al.,21 1998 Pro, NR II 18 N/R N/R 50% 32 28 N/R N/R 27 4 Sperber et al.,222001 Pro, R I 30 30 100% 70% 25 24 70% N/R 57.6 ⬎1 Steinbeck and Jerosch,23 1998 Pro, NR II 30 30 100% 80% 27.5 36 77% N/R N/R 6.35 Tan et al.,24 2006 Pro, R I 130 124 (63) 95% 63% 27 31.2 85% N/R 21.6 ⬎1 124 (61) 95% 54% 28 28.8 88% N/R 25.2 ⬎1 Magnusson et al.,252006 Pro, R I 40 40 (20) 100% 60% 26 25 70% N/R 34 3 40 (20) 100% 60% 30 26 70% N/R 34 5
extracted from the studies (Table 1). In the primary instability group there were 4 randomized controlled trials (Level I) and 1 nonrandomized prospective co-hort study (Level II). The RI group had 6 randomized controlled trials (Level I) and 4 prospective cohort studies (Level II). The number of patients enrolled in the FT instability group ranged from 10 to 43, with an effective follow-up of 84% to 100%. The RI studies’ enrollment ranged from 18 to 130, with an effective follow-up of 95% to 100%. All patients in the FT dislocation group had surgery after the first episode of instability at a mean of 5.5 to 10 days after the traumatic episode. Patients in the RI group had a mean of 3 recurrent episodes to “multiple” recurrent epi-sodes and had a mean duration of symptoms of 22 to 58 months before surgical intervention. In each study the demographics of the study groups were compared, and we did not find any statistically significant differ-ences in age, dominant extremity, gender, follow-up, concomitant pathologies, number of episodes, or time to surgery.
Surgical Technique
All studies described an arthroscopic method for repair of the essential “Bankart” lesion (Fig 1, Table 2). Three studies in the FT group described a transgle-noid technique26 for labral repair with a mean of 2
sutures.3,5,6One study in the FT group used a mean of
2.1 bioabsorbable tacks (Suretac; Smith & Nephew Endoscopy, Andover, MA) for repair,4and one study
used a mean of 4.2 suture anchors (Panalok; DePuy Mitek, Raynham, MA).7 In the RI group 2 studies
performed a transglenoid technique for repair.15,23
Five studies used between 2 and 3 knotless bioabsorb-able tack devices for fixation (Suretac [Smith & Nephew Endoscopy] or Bionx [Linvatec, Largo, FL]).12,16,21,22,25
The remaining 3 studies repaired the Bankart lesion with 3 to 5 suture anchors including both metal anchors (mini-Revo [Linvatec] or GII [DePuy Mitek])13,24and
absorb-able anchors (Bio-FASTak [Arthrex, Naples, FL] or Pan-alok [DePuy Mitek])11,24 (Video 1, available at www.
arthroscopyjournal.org). All implants were placed in an effort to reproduce the anatomy of the anteroinferior labrum and restore the “bumper” of the capsulolabral complex (Fig 2).
Concomitant SLAP pathology and repair were de-scribed in 5% to 20% of patients with FT instability3-7
and in 2 studies (10% to 25%) in the RI group.11,24
The remainder of the studies either excluded patients with additional pathology12,13,25 or did not mention
concomitant pathology.15,16,21-23 The incidence of an
associated Hill-Sachs lesion at the time of arthroscopy ranged from 90% to 100%. Bottoni et al.,11in the RI
group, further divided the patient group into those with Bankart lesions at the time of arthroscopy (25%) and those with anterior labroligamentous periosteal sleeve avulsion, which was found in 59% of patients. Finally, the incidence of an osseous bony Bankart lesion ranged from 9% to 24% in the FT instability group3,7and from 3% to 5% in the RI group.15,24All
authors described the bony pathology as involving less than 20% of the glenoid surface and being incorpo-rated into the repair at the time of surgery.
Rehabilitation
The postoperative rehabilitation protocol was simi-lar among all studies evaluated and included a period of immobilization for 3 to 6 weeks postoperatively, followed by an active range-of-motion program at 3 to 6 weeks and strengthening at 6 to 12 weeks. Patients were allowed to return to their preinjury sport at a mean of 4 to 8 months postoperatively.
Recurrence
The five studies describing surgical repair for FT instability had a recurrence rate of 7% to 16% (Table 3). Three studies that described a transglenoid suture technique for repair of the anteroinferior capsulolabral complex had the highest rates of recurrence in this
FIGURE1. Arthroscopic image of a classic Bankart lesion in a right shoulder. The anteroinferior labrum is avulsed from the anterior glenoid (arrow). The patient in this image is in the left lateral decubitus position. The arthroscope is in the posterior view-ing portal lookview-ing anterior across the glenoid surface.
group, at 15% to 16%.3,5,6 The one study that
de-scribed fixation with a bioabsorbable tack had an overall recurrence rate of 11%.4The lowest recurrence
rate was seen in the patients with suture anchor repair of the Bankart lesion, at only 7%.7There was some
variation in the definition of “failure” and therefore “recurrence.” Arciero et al.3and Bottoni et al.4defined
recurrence as any episode of repeat dislocation or if there was any subjective experience of instability. Robinson et al.7used the same definition, plus
addi-tional confirmation by positive apprehension on ex-amination. The remaining 2 studies in the FT insta-bility group simply defined failure and recurrence as
any repeat episode of dislocation postoperatively and did not include any subjective complaints or evidence of instability by examination.5,6
The 10 studies that evaluated arthroscopic Bankart repair after multiple episodes of RI had a recurrence rate of 0% to 30% (Table 3). In the 2 studies that evaluated the effectiveness of a transglenoid suture technique for arthroscopic repair, the recurrence rate was 10% to 30%.15,23 These authors defined
recur-rence as a repeat episode of dislocation or a subjective complaint of subluxation confirmed by positive appre-hension on examination. Steinbeck and Jerosch23
de-scribed variable recurrence rates: 17% among patients
TABLE2. Surgical Technique
Source Surgical Technique No. of Points of Fixation Labrum-Bone Fixation Concomitant Pathology Bony Bankart Rehabilitation FT
Arciero et al.,31994 Arthro 2 TG SLAP (2), HS (19) 24% I: 4 wk
Bottoni et al.,42002 Arthro 2.1 BT (Suretac; SNO) SLAP (2), HS (10) I: 4 wk, AA: 4 wk, S: 4
wk, RTS: 4 mo
Kirkley et al.,51999 Arthro 2 TG SLAP (1), HS (18) I: 3 wk, AA: 4-6 wk, S:
9 wk, RTS: 4 mo
Kirkley et al.,62005 Arthro 2 TG SLAP (1), HS (18) I: 3 wk, AA: 4-6 wk, S:
9 wk, RTS: 4 mo Robinson et al.,72008 Arthro 4.2 SA (Panalok; DM) SLAP (8), HS (45) 9% I: 6 wk, AA: 6-12 wk,
S: 12 wk RI
Bottoni et al.,112006 Arthro 5 SA (Bio-FASTak;
Arthrex)
SLAP (8), Bankart (8), ALPSA (19)
I: 4 wk, A: 4-8 wk, S: 8 wk
Cole et al.,122000 Arthro 2 to 3 BT (Suretac; SNO) Excluded I: 4 wk, S: normal
ROM, RTS: 8 mo Fabbriciani et al.,13 2004 Arthro 3 SA (mini-Revo; Linvatec) Excluded I: 3 wk, S: 3 mo, RTS: 6 mo Jorgensen et al.,15 1999 Arthro N/R TG HS (21) 5% I: 3 wk, P/A: 3-6 wk, RTS: 12 wk Karlsson et al.,16 2001 Arthro N/R BT: extra-articular (8), intra-articular (52) (Suretac; SNO) N/R I: 4 wk, A: 4 wk, S: 6 wk, RTS: 6 mo
Kartus et al.,211998 Arthro 2.55 BT: intra-articular
(11), extra-articular (7) (Suretac; SNO)
N/R I: 4 wk, A: 4 wk, S: 4
wk, RTS: 6 mo
Sperber et al.,222001 Arthro 2 BT (Suretac; SNO) N/R I: 3 wk, A: 6 wk, RTS:
6 mo Steinbeck and
Jerosch,231998
Arthro N/R TG HS (30) I: 4 wk, A: 6 wk, RTS:
6 mo
Tan et al.,242006 Arthro 3 SA (GII; DM) SLAP (6) 3% I: 3 wk, A: 3 wk
Arthro 3 SA (Panalok; DM) SLAP (6) 3% I: 3 wk, A: 3 wk
Magnusson et al.,25
2006
Arthro 2.88 BT (Bionx; Linvatec) Excluded I: 4 wk, S: 4 wk, RTS:
6 mo
Arthro 2.88 BT (Suretac; SNO) Excluded I: 4 wk, S: 4 wk, RTS:
6 mo
Abbreviations: Arthro, arthroscopic; TG, transglenoid; HS, Hill-Sachs; I, immobilization; BT, bioabsorbable tack; SNO, Smith & Nephew Endoscopy; AA, active assisted range of motion; S, strength; RTS, return to sport; SA, suture anchor; DM, DePuy Mitek; ALPSA, anterior labroligamentous periosteal sleeve avulsion; ROM, range of motion; P, passive range of motion; A, active range of motion; N/R, not recorded.
with dislocation only versus 30% among those with either an episode of dislocation or subjective sublux-ation. The 5 studies that performed fixation with a variable number of knotless bioabsorbable tack de-vices had recurrence rates of 0% to 24%.12,16,21,22,25
All of the authors performing bioabsorbable tack fix-ation described failure as any recurrent episode of dislocation or subluxation. Magnusson et al.25 also
evaluated patients’ discomfort at maximal external rotation and found that 15% to 45% of patients had pain with this provocative maneuver but no sense of instability. Finally, the 3 studies with suture an-chor fixation described recurrence rates of 0% to 11%.11,13,24Recurrence was again defined as
shoul-der dislocation or subjective subluxation.
Postoperative Range of Motion, Strength, and Outcome Scores
There was great variation in the tools used to mea-sure patient outcome postoperatively among the stud-ies reviewed (Table 4). Within each independent study, there was a statistically significant improve-ment in outcome scores from preoperatively to post-operatively. However, the only comparison in out-come measures between groups was in Rowe scores. Eighty-eight percent of patients reported a good or excellent Rowe score in the FT dislocation group after bioabsorbable tack fixation4 compared with 76% to
99% of patients with similar fixation in the RI group.12,21Because of the variability in outcome
mea-sures recorded or arthroscopic technique, however, no other direct comparison could be made between FT instability and RI outcome measures. Similarly, vari-ation in technique for range-of-motion and strength measurements prevented an accurate comparison be-tween the FT and RI groups. However, among the FT instability group, patients regained greater than 85% of external rotation (neutral abduction), 95% of for-ward elevation, 93% of external rotation at 90° of abduction, and 98% of internal rotation when com-pared with the unaffected extremity.5 Similarly,
pa-tients in the RI group regained nearly 100% of for-ward elevation and abduction, 90% of external rotation (neutral abduction), and 80% to 90% of ex-ternal rotation at 90° of abduction and were within 1 level of internal rotation compared with the nonopera-tive extremity.11,12,16,21,22,25
Complications
There were few complications recorded among pa-tients in either group. Among papa-tients undergoing surgery after primary dislocation, 2 patients had ad-hesive capsulitis postoperatively, described as a “se-vere” restriction in external rotation.7One of the two
patients was successfully treated with an aggressive course of physical therapy and the other with an arthroscopic release of the rotator interval and capsule followed by manipulation under anesthesia. Two pa-tients had transient median nerve paresthesias that resolved by 3 weeks postoperatively,3 and two
pa-tients had superficial infections.3,7In the RI group 7
patients had adhesive capsulitis postoperatively with a “severe” restriction in range of motion.12,16,25Of these
7 patients, 3 had resolution of their symptoms after a course of physical therapy, 3 required additional sur-gery to regain motion, and in 1 moderate osteoarthritis developed.25 The RI group also had 2 patients with
anchor pullout,16,221 with a transient paresthesia
(ul-nar sensory), 3 with a superficial infection, and 8 with painful sutures or incisions that resolved by the final follow-up.15,22,25
DISCUSSION
The technique of and surgeon experience with ar-throscopic Bankart repair for shoulder instability have now evolved to the point that the results of arthro-scopic repair are at least equal to those of the gold standard open repair technique.14 The arthroscopic
FIGURE2. Arthroscopic image of right shoulder after repair of labral tear with suture anchors. There is restoration of the labral “bumper” (arrow). The patient in this image is in the left lateral decubitus position. The arthroscope is in the posterior viewing portal looking anterior across the glenoid surface.
technique has shown clear improvement in patient subjective and objective outcome scores with a low risk of complications.11-13,16,21,22,24,25In addition,
sev-eral studies have supported early versus late surgical repair in young active patients for shoulder instabi-lity.3-7,19 The argument in favor of early repair
in-cludes a reduction in recurrence rate of 70% to 90% when compared with conservative treatment. In addi-tion, some investigators believe that earlier surgery prevents the development of additional intra-articular pathology, including glenoid bone loss, increased fre-quency of Hill-Sachs lesions, and more extensive chondral injuries. Studies have shown significant at-trition of the capsular and bony structures with recur-rent episodes of instability, which may lead to poor tissue quality and difficulty in reproducing normal anatomy.27,28At the time of definitive surgery in these
patients, one may expect diminished outcomes when compared with those with more healthy, intact tis-sue at the time of the initial injury. Finally, there has been little information about quality of life in patients with recurrent shoulder instability. One may presume that a low recurrence rate after pri-mary repair and a rapid return to preinjury activities would allow for improved quality of life compared with those having countless episodes of recurrence over months and years with an inability to return to a normal active life. However, there is very little objective measurement of the patient’s quality of life after a shoulder dislocation.
The purpose of this systematic review was to try to answer the question: Does arthroscopic repair in pa-tients with anterior shoulder instability after the pri-mary dislocation improve the recurrence rate,
func-TABLE3. Recurrence Rate, Technique, and Description of Failure
Source Labrum-Bone Fixation
Overall Recurrence
Mean Time to
Recurrence (mo) Failure Definition FT
Arciero et al.,31994 TG 15% Subluxation or dislocation
Bottoni et al.,42002 BT (Suretac; SNO) 11% Subluxation, dislocation, inability to full
active duty, or second procedure
Kirkley et al.,51999 TG 16% Dislocation
Kirkley et al.,62005 TG 16% Dislocation
Robinson et al.,72008 SA (Panalok; DM) 7% 11.3 Subluxation or dislocation plus
apprehension on examination RI
Bottoni et al.,112006 SA (Bio-FASTak; Arthrex) 4% Pain only, no instability
Cole et al.,122000 BT (Suretac; SNO) 24% Subluxation, dislocation, or positive
apprehension on examination Fabbriciani et al.,132004 SA (mini-Revo; Linvatec) 0% Subluxation or dislocation
Jorgensen et al.,151999 TG 10% Subluxation, dislocation, or positive
apprehension on examination Karlsson et al.,162001 BT: extra-articular (8),
intra-articular (52) (Suretac; SNO)
15% Subluxation or dislocation
Kartus et al.,211998 BT: intra-articular (11),
extra-articular (7) (Suretac; SNO)
0% Dislocation
Sperber et al.,222001 BT (Suretac; SNO) 23% 13 Subluxation or dislocation
Steinbeck and Jerosch,23
1998
TG 17%/30% Dislocation or positive apprehension on
examination
Tan et al.,242006 SA (GII; DM) 6% Dislocation or positive apprehension on
examination
SA (Panalok; DM) 11% Dislocation or positive apprehension on
examination
Magnusson et al.,252006 BT (Bionx; Linvatec) 5%/45% Dislocation/discomfort at maximal ER
and no instability
BT (Suretac; SNO) 5%/15% Dislocation/discomfort at maximal ER
and no instability
Abbreviations: TG, transglenoid; BT, bioabsorbable tack; SNO, Smith & Nephew Endoscopy; SA, suture anchor; DM, DePuy Mitek; ER, external rotation.
Source Constant OISS VAS SF-12 PS SANE Rowe
Rowe
WOSI DASH SST UCLA ASES RTS Satisfaction Excellent Good Fair Poor
FT Arciero et al.,3 1994 88 76% 10% 0% 14% Bottoni et al.,4 2002 67% 22% 0% 11% Kirkley et al.,5 1999 287.01 (290.19) Kirkley et al.,6 2005 95.8 94.7 Robinson et al.,72008 ⬃98 94% RI Bottoni et al.,112006 93.5 (8.3) 91.6 433.6 (443.6) 11.4 (1.2) 32.1 (2.7) Cole et al.,12 2000 83 62% 14% 19% 5% 87 46% 84% Fabbriciani et al.,132004 89.5 (4.25) 91 (15.06) Jorgensen et al.,151999 62 92.5 Karlsson et al.,162001 91 93 Kartus et al.,21 1998 96 92 67% 33% 0% 0% Sperber et al.,222001 100 100 Steinbeck and Jerosch,23 1998 83.1 (21.6) 83% Tan et al.,24 2006 18 (6) 0.3 (0.7) 50 (9) 85% 20 (10) 0.7 (1.6) 54 (8) 85% Magnusson et al.,252006 84 90 87 90
NOTE. Values are mean (standard deviation).
Abbreviations: OISS, Oxford Instability Shoulder Score; VAS, visual analog scale; SF-12 PS, Short Form 12 Questionnaire Physical Score; SANE, Single Assessment Numeric Evaluation; DASH, Disabilities of the Arm, Shoulder and Hand; SST, Simple Shoulder Test; UCLA, University of California, Los Angeles; ASES, American Shoulder and Elbow Surgeons; RTS, return to sport.
R.
C.
GRUMET
ET
tional outcome, or quality of life when compared with those having surgery after multiple episodes of insta-bility? On the basis of the collection of studies gath-ered to answer this question, there is no apparent difference in overall recurrence or complication rate among patients undergoing surgery after the initial dislocation compared with those repaired after RI. More specifically, when comparing the type of arthro-scopic procedure performed, including modern tech-niques of suture anchor fixation, there is no difference in recurrence. Rates after arthroscopic suture anchor fixation approach those of open techniques.9 With
regard to functional outcome, there was significant improvement in outcome from preoperative to post-operative assessment among independent studies. However, because of the large variability in outcome measures recorded, a true comparison between the outcome variables of patients with FT dislocation and patients with RI was not possible. To assist with cross-comparison of instability studies, it would be prudent in the future to adopt a standardized instability outcome score.
The question of improved quality of life could not be specifically evaluated in this systematic review. However, 1 study evaluated the long-term results after arthroscopic Bankart repair in patients with FT dislo-cation using the WOSI.6 The WOSI is an outcome
instrument used to specifically describe the impact of the patient’s shoulder instability on his or her quality of life. Kirkley et al.6 found an 11% difference in
WOSI score at a mean of 79 months postoperatively when compared with patients treated nonoperatively. Although the difference between the 2 groups was not found to be statistically significant, the authors con-cluded that it was a “small but clinically meaningful difference.” To our knowledge, this is the only scien-tific study that has specifically sought to answer the question: does early surgical intervention improve a patient’s quality of life?
Robinson et al.1 evaluated the functional outcome
and risk of recurrence in a group of active, “high-risk” patients treated with conservative measures after an episode of shoulder instability. They found that insta-bility developed in 56% of patients within the first 2 years after the primary dislocation and increased to 67% by the fifth year of follow-up. They also noted a small difference in functional outcome as measured by the WOSI. This study also suggests that recurrent shoulder instability negatively impacts a patient’s ability to return to preinjury activity level and, there-fore, quality of life.
Study Limitations
As with any systematic review, there are limitations to this study.
Selection Bias: All of the studies in this systematic
review were cohort studies (Level I and Level II). All of the studies provided statistical analysis to ensure homogeneity between comparison groups and there-fore limit the potential for selection bias. In addition, 10 of the 15 studies evaluated were randomized pro-spective clinical studies, which limit bias by experi-mental design. The factors that have been shown to affect clinical outcome, including age, gender, number of episodes, time to surgery, concomitant pathology, and surgical technique, were not found to be statisti-cally significant between groups in each study.
Performance Bias: The technique for arthroscopic
repair was variable between the FT and RI groups. Within each group, there were patients with transgle-noid fixation, bioabsorbable tack fixation, and suture anchor fixation. The variation in technique reflects the evolution in surgical repair for shoulder instability over the years. We attempted to limit performance bias by only comparing recurrence rates among pa-tients receiving a similar arthroscopic procedure. Ide-ally, to eliminate performance bias, we would have preferred to have all patients having identical surgical repair with a similar number of fixation devices, with elimination of the “learning curve” shown arthro-scopic stabilizations.
Performance bias may also occur in studies where a disproportionate number of concomitant procedures were performed or there was variation in the rehabil-itation protocol. Patients in the FT dislocation group all had concomitant SLAP repair; however, only 2 studies in the RI group had SLAP repair at the time of the Bankart repair.11,24The rehabilitation protocol was
not significantly different between groups.
Exclusion Bias: Exclusion bias was limited in this
systematic review because all included studies had greater than 80% (84% to 100%) follow-up, with a mean follow-up near 90%.
Detection Bias: All of the outcome measures used
in this study have been validated as valuable outcome instruments. All studies reported a significant im-provement between preoperative and postoperative assessment within each group. The only comparison in outcome measures between groups was in Rowe scores after bioabsorbable tack fixation, as men-tioned.4,12,21 The remainder of outcome measures
not comparable because of differences in the fixa-tion technique.
CONCLUSIONS
There were no significant differences in the recur-rence rate of instability or complication rate among young active patients undergoing arthroscopic repair for shoulder instability performed after either the pri-mary dislocation or multiple episodes of recurrence. Although there were no apparent differences in out-comes between the FT and RI groups, additional stud-ies are necessary to identify clinical outcome differ-ences between these 2 patient populations. Additional randomized controlled trials are needed to specifically compare the functional outcome, quality of life, and ability to return to preinjury activity level among patients undergoing early versus delayed repair for anterior shoulder instability.
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