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Randomized Trial Finds Arthroscopic Shoulder Surgery Better Than Open Procedure

References: AAOS 72nd Annual Meeting: Abstract 155. Presented Feb. 24, 2005.

Abstract
Arthroscopic surgery for shoulder instability takes significantly less operating time and may cause less discomfort than traditional open surgery, according to a prospective, randomized trial of military personnel.

"The open technique has been considered the gold standard," said Lieutenant Colonel (LTC) Craig R. Bottoni, MD, chief of sports medicine and orthopaedic surgery at Tripler Army Medical Center in Honolulu, Hawaii. "However, this requires cutting the tendons to access the joint. This is fairly extensive exposure that can result in scarring and a limited range of motion."

In a study of 61 consecutive patients (one women), aged 24 to 38 years, arthroscopic surgery required a median time of 52 minutes compared with 163 minutes for the open procedure (P < .001). LTC Bottoni described his findings during a press conference here at the 72nd annual meeting of the American Academy of Orthopaedic Surgeons.

The patients all suffered from dislocating shoulders that prevented them from continuing activities that put heavy strain on the shoulders, such as carrying weapons, LTC Bottoni said. The primary outcome of the study was how soon the patients could return to work.

On all formal measures of shoulder discomfort and functionality, the less-invasive procedure was not statistically different from the open procedure, although there was a trend in favor of arthroscopy, LTC Bottoni reported. Participation in the study was not required of these military patients, although they readily agreed to be studied. One patient who was randomized and received arthroscopic surgery and later became a candidate for surgery on his other dislocating shoulder declined randomization in favor of arthroscopy.

Two (6.9%) of the 29 shoulders treated with an open procedure, and one (3.1%) of the 32 treated arthroscopically were assessed as failures because of persistent pain that interfered with necessary activities.

"The advantages of doing it arthroscopically include a quicker restoration of motion, because you're not cutting through the rotator cuff. The other real advantage is that we can see the rest of the shoulder joint," LTC Bottoni added. "Sometimes we get 360-degree tears. So we have to fix the top, the back, and the front, and we can do all that arthroscopically. We could never do that open."

The surgeries were performed from April 2001 to June 2002. None of the 61 patients experienced recurrent dislocations in the treated shoulder to date, although three additional treated patients were lost to follow-up.

Hospitalization time comparisons might have shown a difference between the two procedures, LTC Bottoni told Medscape, but all patients were automatically hospitalized for one night, as is commonly done in military settings. Military physicians do this because barracks do not provide the support services civilian patients would probably find in their homes, such as helpful family members, he said.

Jeffrey S. Abrams, MD, attending orthropaedic surgeon at the University Medical Center in Princeton, New Jersey, and moderator of the session at which the study was presented, praised the study's randomized design. "I think it's a wonderful study of a group of young, active people," he said. "But it's a fairly homogenous population." He also noted that in military settings, patients who are assigned to physical therapy regimens complete it, which is not true in civilian practice. Such therapy compliance could affect outcomes.

Dr. Abrams and other surgeons at the session estimated that only about 40% to 50% of shoulder surgeries, at most, are currently performed arthroscopically, when for many indications 90% to 100% could be. Both Dr. Abrams and LTC Bottoni predicted that arthroscopy will become the new gold standard procedure for shoulder instability.

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