Arthroscopic shoulder stabilization Differential treatment strategy with Suretac, Fastak, holmium: YAG laser and electrosurgery

Abstract

The goal for arthroscopic stabilization of anterior glenohumeral instability is to achieve an outcome equivalent to or better than open procedures. A number of arthroscopic procedures have been advocated to reestablish continuity of the inferior glenohumeral ligament complex (IGHLC) with the glenoid. Implantable suture anchors were developed to avoid the problems associated with arthroscopic staple capsulorrhaphy like iatrogenic injury of the glenoid or humeral surface, loosening and migration of the staple. Several transosseous techniques include the need for an accessory posterior incision, the possibility of neurovascular injury (Suprascapular or axillary nerve), and the loosening of the repair after tying over the fascia of the infraspinatus posteriorly. The preferred techniques are cannulated, absorbable fixation device (Suretac) and easy implantable suture anchors made of titanium (Fastak). Even in the hands of experienced arthroscopists, unacceptably high recurrence rates for arthroscopic shoulder stabilization have been reported, due to the steep learning curve for both technical performance and patient selection. Our experience suggests, that if proper selection criteria are employed, normal patients and overhead-athletes may benefit from the advantages of an arthroscopic repair without accepting an increased risk for recurrence. We performed a prospective analysis of 105 shoulders, who underwent arthroscopic stabilization with Suretac or Fastak between 4/96 and 7/98. 48 shoulders were available for followup at least one year. The redislocation rate was 6.25 % (3 shoulders) and the rate of subluxation without dislocation also was 6.25 %, but none of the shoulders required a second open stabilization. The reason for redislocation or subluxation were 5/6 traumatic injuries, participating in contact sports or in one case a generalized ligamentous laxity. In combination with the LACS-Procedure or the Electro thermally assisted capsular shift (ETACS) not only the capsular detachment but also the capsular redundancy may be adressed and a lower failure rate can be expected.

Multimodality imaging of the postoperative shoulder

“…The same principal is followed in arthroscopic stabilization (arthroscopic Bankart repair), where the labro-ligamentous complex is repaired by refixation with metallic or bio-absorbable suture anchors placed at the 2-3, 4, and 5 o'clock positions of the glenoid rim. Arthroscopic repair, however, obviates the need for releasing and reattaching the subscapularis [7,9,10,15,16]. In many cases of traumatic instability, surgical repair has to be supported by reduction of capsular volume.…”

“…SLAP repair (Fig. 1c, d) is usually performed arthroscopically with use of suture anchors or tacks, which are placed anteriorly and posteriorly to the biceps anchor at the 10-11 o'clock and 1-2 o'clock positions of the glenoid [8,16,25]. Type 3 SLAP lesions do not impair the stabilizing function of the biceps tendon and therefore are often treated by simple debridement [16,25,33].…”

“…Modern devices are either made of non-ferromagnetic metal, such as titanium, or of bioabsorbable material (polymers), that can be phagyozytized after fragmentation [16,63,64]. Biodegradable devices are resorbed in a time period ranging from months to several years, depending on the specific biomaterial used [64].…”

“…In arthroscopic repair, sufficient capsular reduction can usually be achieved by arthroscopically performed capsulorhaphy and rotator interval closure [18,19]. Laser-assisted capsular shrinkage (LACS) and electrothermally assisted capsular shift (ETACS) are controversially discussed alternative techniques to tighten the capsule arthroscopically by controlled denaturation of capsular collagen fibers with application of laser or thermal energy, respectively [16].…”

“…Open Bankart repair is often combined with a capsular shift procedure, such as the Neer procedure (Table 1). Inferior capsular shift is as well used as a primary treatment in patients with atraumatic multidirectional shoulder instability [16,17]. In arthroscopic repair, sufficient capsular reduction can usually be achieved by arthroscopically performed capsulorhaphy and rotator interval closure [18,19].…”