Is Open Stabilization Superior to Arthroscopic Stabilization for the Treatment of Recurrent Traumatic Anterior Shoulder Instability?

Commentary A recent analysis of data from the American Board of Orthopaedic Surgery (ABOS) Certification Examination revealed that the use of open Bankart repair for glenohumeral dislocation is declining1. Indeed, the authors of several recent reports have suggested that arthroscopic stabilization for recurrent traumatic anterior shoulder instability with use of modern techniques yields similar recurrence rates to that of open stabilization2-4. Mohtadi et al. called this idea into question and provided evidence to the contrary in a well-powered prospective randomized trial. These authors compared arthroscopic and open stabilization in a large group of patients with recurrent traumatic anterior glenohumeral instability. A particular strength of the study was the matching of surgeons according to years of experience. Two surgeons performed the open repairs and three surgeons performed the arthroscopic repairs. The two surgeons contributing the most patients to the study each had ten years of experience in open and arthroscopic procedures, respectively, thus minimizing bias in surgical expertise between groups. On the basis of the results of the study, which showed no difference in postoperative Western Ontario Shoulder Instability Index (WOSI) and American Shoulder and Elbow Surgeons (ASES) scores at two years, and a significantly higher recurrence rate in the arthroscopic group, the authors suggested that open repair should be considered for the “high-risk” subgroup of younger males with a Hill-Sachs lesion as seen on radiographs. There are, however, a few unresolved questions that may prevent an unequivocal endorsement of open repair in this setting. The rate of participation in contact or collision sports, although not significantly different between groups, was higher in the arthroscopic group (56% versus 44%). Contact or collision-sport involvement is a known risk factor for recurrent instability and thus might have negatively influenced the rate of recurrence in the arthroscopic group. Looking specifically at the subgroup at increased risk for recurrence in this study, namely males twenty-five years of age or younger with a Hill-Sachs lesion, the recurrence rate was indeed lower in the open group (26% versus 38%). However, this difference did not reach significance, which perhaps tempers the conclusion that these patients should be treated with open repair. In addition, the relatively high recurrence rates noted for both arthroscopic and open repair in this high-risk subgroup raise the question of whether suture anchor repair alone is adequate for such patients. Additional high-quality research studies are required to determine definitive indications for remplissage and/or bone-transfer procedures, such as the Latarjet procedure, in high-risk individuals. The authors should be commended on an excellent study that makes a substantial contribution to the current body of literature. It lends further support to the idea of the open anterior stabilization procedure as the “gold standard” to which arthroscopic results should continue to be compared.

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