Arthroscopic
vs. Open Stabilisation
Larry D. Field, MD
Mississippi
Sports Medicine Center
Jackson,
Mississippi
I. Decision Making - The decision
regarding the use of an arthroscopic or open technique for shoulder stabilization
depends on many factors. Likewise, assessing the relative advantages
and disadvantages of techniques for stabilization involves a number of
important parameters.
What
does "better" mean?
- lower recurrence rate?
- less invasive?
- improved motion postoperatively?
- lower complication rate?
- technically easier?
- all of the above?
II. Goal of surgical intervention -
The best procedure for shoulder instability would result in no postoperative
recurrences, normal postoperative motion, no postoperative pain and a
return to preinjury performance levels in all patients undergoing the
intervention. Certainly, no technique currently available can satisfy
these requirements. However, critical assessment of the various open
and arthroscopic procedures now available allows for some determination
of relative merit.
III. Not a black and white issue -
No single technique for shoulder stabilization is always best. Numerous
factors must be considered in the evaluation of the patient in order
to determine the best operation for that individual.
A.
Some of the factors that must be considered include:
1.
Pathology
-
Bankart lesion with healthy, robust labroligamentous tissue
vs.
-
Patulous, thin and poorly defined capsuloligamentous tissue without a
Bankart lesion
2.
Instability pattern
Anterior
vs.Posterior vs.MDI
3.
Technique
- Open:
Bankart vs. Magnuson-Stack
- Arthroscopic:
Bankart vs.Transglenoid capsulorrhaphy vs.Thermal capsulorrhaphy
4.
Patient
- 21
year old college pitcher with dominant-sided instability
vs.
-
16 year old offensive tackle with non-dominant instability
5. Surgeon
-
Technical capabilities
500
shoulder arthroscopies per year vs.
10
shoulder arthroscopies per year
- Tolerance for
failure -What’s acceptable? 2%, 5%, 10%, 20%? The literature is full
of contradictory statements regarding the acceptability of recurrence
rates. Acceptable outcomes differ from patient to patient and surgeon
to surgeon. No widely accepted figure is available on what recurrence
rate is acceptable.
No
prospective, randomized studies exist comparing arthroscopic techniques
with open techniques. Several prospective non-randomized studies suggest
increased recurrence rates with arthroscopic techniques but also improved
motion and reduced pain. (Weber (1991) and Jorgensen (1995)) Several
retrospective, non-randomized studies have also been presented and generally
suggest similar results.
IV. Parameters for consideration -
Very few conclusions are possible when all arthroscopic procedures are
considered as a group and all open procedures are considered as well.
Likewise, bulking all instability patterns into a discussion of the efficacy
of arthroscopic vs. open techniques diminishes the value of any conclusions
to be drawn. For this reason, limiting the discussion to a specific group
of parameters will allow for more valid conclusions.
A.
The following parameters can serve as guides for consideration:
1.
Pathology
-
Traumatic, recurrent anterior dislocator with a Bankart lesion
2.
Surgical technique
-
Open Bankart (axillary incision, outpatient surgery, subscapularis split
or release)
vs.
-
Arthroscopic Bankart (suture anchors or suretacs) or transglenoid capsular
shift
3.
Patient
-
17 year old high school linebacker with 5 previous
dislocations
4.
Surgeon (Your Name Here)
- Experience
- Technical abilities
- Tolerance
B.
Limiting our discussion to these parameters leaves only one variable: the
surgeon. Based on these restrictive parameters, several facts can
be stated:
I.
Recurrences less likely with open stabilization.
2.
Loss of motion less with arthroscopic techniques.
3.
Inpatient vs. outpatient? Open more likely to be admitted although open
can be routinely carried out as outpatient.
4.
Cost: Arthroscopic less only if open patient admitted (also, cost of
recurrent instability must be considered)
5.
Length of operative time (1 hour or less required regardless of technique
for experienced surgeon)
6.
Recovery time: no significant difference unless recovery of motion difficult
7.
Cosmesis: arthroscopy superior although axillary incision cosmetically
pleasing
V. Conclusions
I.
Recurrence rate lower with open stabilization but motion generally better
with arthroscopic techniques (motion and stability mutually exclusive?)
2.
Neither technique is "easy".
3.
Surgical technique ultimately chosen should be based on surgeon’s experience,
technical ability with the arthroscope, specifics of the pathology including
the instability pattern, and aspirations and activity level of the patient
postoperatively.
4.
Tailor the operation to the patient and not the patient to the operation.