**7. Arthroscopic or open treatment?**

Recent advances in suture technology and instrumentation and increasing surgeon experience have broadened the application of all-arthroscopic shoulder stabilization techniques. Open surgical procedures were thought to restrict external rotation and lead to secondary osteoarthritis. Additional disadvantages included wide surgical dissection and scarring. On the contrary, arthroscopic procedures were associated with reduced postoperative pain, earlier rehabilitation and less restriction of movement (Green & Christensen, 1993). Shoulder arthroscopy also provides improved articular visualization intra-operatively and allows for the preservation of the subscapularis.

Although initial results from comparison studies between arthroscopic and open procedures indicated significantly higher rates of recurrence (13%-70% compared with

Bankart lesions, which are most commonly seen after recurrent shoulder dislocations, were first described in 1923 as "shearing of the fibrous capsule of the joint from its attachment to the fibro-cartilaginous glenoid ligament". For decades, open repair of Bankart lesions was considered the gold standard, with success rates reaching up to 97%

Arthroscopic techniques for the repair of these lesions were not introduced until 1982, when Johnson first described the arthroscopic use of staples as a modification of the open procedure (Johnson, 1980). However, this technique produced unacceptably high rates of recurrence along with hardware loosening or migration, which subsequently limited its use. Transosseous sutures for arthroscopic Bankart repair were introduced in 1987 (Morgan & Bodenstab, 1987). The sutures were passed through the scapular neck, exited posteriorly and were tied over the posterior fascia. Although excellent results were reported originally, they were not confirmed by follow-up studies. Disadvantages of this technique included the need for knot tying over the posterior fascia and the risk of iatrogenic injury to the suprascapular nerve. Removable arthroscopic rivets and absorbable cannulated bio-tacks have also been

Suture anchors present the latest technological advance in arthroscopic shoulder instability repair. They were first introduced in 1993 (Wolf, 1993). The advantages of their use include multiple points of fixation, no posterior glenoid penetration and increased pullout strength, which in the case of later-generation suture anchors is comparable to transosseous suture fixation. Suture anchors traditionally used for labral repairs are either push-in or screw-in

Each anchor commercially available is unique with regard to its pull-out strength, type of suture, retrievability, bioabsorbability, insertion technique and cost. The ideal characteristics include strength and sturdiness at the time of insertion, fixation strength and safe biologic replacement of the glenoid as the anchor resorbs. Various types of suture anchors are currently available, including metal, bioabsorbable, and bioinert. Metallic anchors have raised concerns of migration or potentially complicating revision surgery. Absorbable anchors were developed later, but concerns remain regarding bone giant cell reaction during the dissolving process. An additional concern is raised by the friction of the sliding knots, which may increase the temperature adjacent to the eyelet of most anchors currently

Recent advances in suture technology and instrumentation and increasing surgeon experience have broadened the application of all-arthroscopic shoulder stabilization techniques. Open surgical procedures were thought to restrict external rotation and lead to secondary osteoarthritis. Additional disadvantages included wide surgical dissection and scarring. On the contrary, arthroscopic procedures were associated with reduced postoperative pain, earlier rehabilitation and less restriction of movement (Green & Christensen, 1993). Shoulder arthroscopy also provides improved articular visualization intra-operatively

Although initial results from comparison studies between arthroscopic and open procedures indicated significantly higher rates of recurrence (13%-70% compared with

used with promising results but without gaining wide popularity.

available, and consequently compromise fixation.

and allows for the preservation of the subscapularis.

**7. Arthroscopic or open treatment?** 

**6. History of the procedure** 

(Rowe et al, 1978).

anchors.

0%-30% respectively), improvements in patient selection and operative technique have steadily decreased recurrence rates to match that of open procedures (Geiger et al, 1997; Roberts et al, 1999; Fabbriciani et al, 2004). In a systematic meta-analysis, which included 62 studies and 3044 arthroscopic operations, no difference was found in failure rates between open and arthroscopic treatment of anterior shoulder instability with suture anchors or bio-absorbable tacks. On the contrary, there was a higher rate of failure compared with open techniques when staples or transglenoid sutures were used arthroscopically (Hobby et al, 2007).

However, data from prospective randomized trials are still limited. Fabbriciani et al found no difference between open and arthroscopic repair of isolated Bankart lesions in a group of 60 patients at 2-year follow-up (Fabbriciani et al, 2004). Similarly, Bottoni et al found no differences in functional scores and recurrence rates between open and arthroscopic techniques for isolated anterior instability repair. However, a trend was established towards improved external rotation and forward flexion as well as significantly reduced operative time in the group of arthroscopic repair. The authors concluded that the latter was equivalent to the open surgical technique for anterior shoulder instability repair (Bottoni et al, 2006).
