Effectiveness of arthroscopic versus open surgical stabilisation for the management of traumatic anterior glenohumeral instability.

Centre for Health, Exercise and Sports Medicine and Rehabilitation Sciences Research Centre, School of Physiotherapy, The University of Melbourne, Melbourne, Victoria, and Centre for Allied Health Evidence (a collaborating centre of The Joanna Briggs Institute), University of South Australia, Adelaide, South Australia, Australia.
International Journal of Evidence-Based Healthcare 06/2007; 5(2):182-207. DOI: 10.1111/j.1479-6988.2007.00064.x
Source: PubMed

ABSTRACT Background  Anterior instability is a frequent complication following a traumatic glenohumeral dislocation. Frequently the underlying pathology associated with recurrent instability is a Bankart lesion. Surgical correction of Bankart lesions and other associated pathology is the key to successful treatment. Open surgical glenohumeral stabilisation has been advocated as the gold standard because of consistently low postoperative recurrent instability rates. However, arthroscopic glenohumeral stabilisation could challenge open surgical repair as the gold standard treatment for traumatic anterior glenohumeral instability. Objectives  Primary evidence that compared the effectiveness of arthroscopic versus open surgical glenohumeral stabilisation was systematically collated regarding best-practice management for adults with traumatic anterior glenohumeral instability. Search strategy  A systematic search was performed using 14 databases: MEDLINE, Cumulative Index of Nursing and Allied Health (CINAHL), Allied and Complementary Medicine Database (AMED), ISI Web of Science, Expanded Academic ASAP, Proquest Medical Library, Evidence Based Medicine Reviews, Physiotherapy Evidence Database, TRIP Database, PubMed, ISI Current Contents Connect, Proquest Digital Dissertations, Open Archives Initiative Search Engine, Australian Digital Thesis Program. Studies published between January 1984 and December 2004 were included in this review. No language restrictions were applied. Selection criteria  Eligible studies were those that compared the effectiveness of arthroscopic versus open surgical stabilisation for the management of traumatic anterior glenohumeral instability, which had more than 2 years of follow up and used recurrent instability and a functional shoulder questionnaire as primary outcomes. Studies that used non-anatomical open repair techniques, patient groups that were specifically 40 years or older, or had multidirectional instability or other concomitant shoulder pathology were excluded. Data collection and analysis  Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion with an independent researcher. Studies were assessed for homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format; otherwise a meta-analysis was conducted. Results  Eleven studies were included in the review. Two were randomised controlled trials. Evidence comparing arthroscopic and open surgical glenohumeral stabilisation was of poor to fair methodological quality. Hence, the results of primary studies should be interpreted with caution. Observed clinical heterogeneity in populations and outcomes was highlighted and should be considered when interpreting the meta-analysis. Authors also used variable definitions of recurrent instability and a variety of outcome measures, which made it difficult to synthesise results. When comparable data were pooled, there were no significant differences (P > 0.05) between the arthroscopic and open groups with respect to recurrent instability rates, Rowe score, glenohumeral external rotation range and complication rates. Conclusions  Statistically, it appears that both surgical techniques are equally effective in managing traumatic anterior glenohumeral instability. In light of the methodological quality of the included studies, it is not possible to validate arthoscopic stabilisation to match open surgical stabilisation as the gold standard treatment. Further research using multicentred randomised controlled trials with sufficient power and instability-specific questionnaires with sound psychometric properties is recommended to build on current evidence. The choice of treatment should be based on multiple factors between the clinician and the patient.

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    ABSTRACT: Purpose To compare the clinical outcome between the use of knotless sutures versus knot-tying sutures in arthroscopic Bankart repairs. Methods Between January 2007 and January 2011, 87 patients who underwent arthroscopic Bankart repair with the use of knot-tying suture anchors or knotless suture anchors were evaluated, with 45 patients in the knot-tying suture group and 42 patients in the knotless group. Patients were assigned to either group, with odd-numbered patients going to the knot-tying suture arm and even-numbered patients assigned to the knotless arm. Outcomes included the Constant score, the visual analog scale (VAS) score, patient satisfaction score, and range of motion in forward flexion and external rotation with the arm in adduction. Redislocations or subluxations with the 2 techniques was also studied. Results Both groups showed a statistically significant improvement between the preoperative and postoperative VAS scores and Constant scores. In the knot-tying suture group, the VAS score improved from 2.5 ± 2.3 to 0.7 ± 0.5 (P < .05) and the Constant score improved from 64 ± 7 to 92 ± 10 (P < .05). In the knotless group, the VAS score improved from 2.8 ± 2.5 to 0.9 ± 0.6 (P < .05), and the Constant score improved from 62 ± 6 to 89 ± 9 (P < .05). The patient satisfaction scores were 6.9 and 7.1 for the knot tying and knotless groups, respectively. No statistically significant differences were found when comparing the outcomes between the 2 groups. The change in the range of forward flexion and external rotation was also similar in the 2 groups. There was also no difference in recurrence or redislocation rates. Conclusions Both the knot-tying and knotless suture anchors groups showed statistically significant and similar improvement in VAS and Constant scores. Both anchors provided reasonable outcomes. The knotless suture anchor is a good alternative to knot-tying suture anchors so that arthroscopic Bankart repairs can be performed without knot tying. Level of Evidence Level II, prospective comparative study.
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