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Luxation Arthroscopic shoulder stabilization techniques are subject to continuous development and are increasingly replacing the open procedure in routine clinical practice. The primary success criterion for stabilization operations is still the postoperative recurrence rate. The extent to which arthroscopic techniques deliver equivalent results to the open standard was investigated in a meta-analysis that compared the results of the corresponding studies between 1985 and 2006.
The results showed that the postoperative outcome of arthroscopic surgery depends significantly on the surgical technique used 2. While arthroscopic staple fixation (recurrence rate: 23%) and transglenoid suture techniques (recurrence rates inhomogeneous: 8-60%) were shown to have significantly worse results compared to open Bankart fixation (recurrence rate: around 10%), arthroscopic suture anchor techniques showed equivalent results (recurrence rate: 8.9%).
With regard to the optimal timing of surgery, there is still no prospective randomized study that demonstrates a clear advantage of patients treated immediately after the initial dislocation compared to patients treated secondarily, i.e. after one or more recurrent dislocations.
As there are no reliable data for an acute surgical procedure after traumatic initial dislocation, a conservative approach using temporary immobilization is still justified. Itoi (Itoi E, Hatakeyama Y, Sato T et al (2007) Immobilization in external rotation after shoulder dislocation reduces the risk of recurrence. A randomized controlled trial. J Bone Joint Surg Am 89(10):2124-2131) showed in a prospective randomized study that the reduction of the labrum to the anterior glenoid rim is more successful when the arm is immobilized in external rotation.
The recurrence rate in the external rotation group was significantly reduced compared to patients with immobilization in internal rotation (26 vs. 42%). The underlying principle is an improved reduction of the labrum by tightening the anterior capsule. Magnetic resonance imaging showed that an external rotation of 30° was sufficient. Immobilization in full external rotation offered no further advantage in terms of labral reduction to the anterior edge of the acetabulum. A 5-week immobilization also showed no advantages over a 3-week interval, so that the latter is recommended in favour of earlier mobilization.
LIN, K. M. et al. Pediatric and adolescent anterior shoulder instability: clinical management of first-time dislocators. Curr Opin Pediatr, v. 30, n. 1, p. 49-56, 02 2018. ISSN 1531-698X. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/29135565 >.
HETTRICH, C. M. et al. Epidemiology of the Frequency, Etiology, Direction, and Severity (FEDS) system for classifying glenohumeral instability. J Shoulder Elbow Surg, v. 28, n. 1, p. 95-101, Jan 2019. ISSN 1532-6500. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/30348544 >.
KARDOUNI, J. R.; MCKINNON, C. J.; SEITZ, A. L. Incidence of Shoulder Dislocations and the Rate of Recurrent Instability in Soldiers. Med Sci Sports Exerc, v. 48, n. 11, p. 2150-2156, 11 2016. ISSN 1530-0315. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/27327025 >.
Particularly in the case of large rotator cuff tears, the question arises as to whether acceptable results can also be achieved with conservative treatment. In patients with relatively good motor compensation and low pain levels, it was shown1; 2 that active shoulder joint mobility remained constant under conservative treatment over a period of 4 years after initial diagnosis (final status: 136° anteversion and abduction, 39° external rotation). However, the general shoulder function, including the pain and strength parameters, was expressed in an only moderate Constant-Murley shoulder function score. X-rays showed progression of the decentration of the humeral head upwards by an average of 3 mm, as well as progression of the glenohumeral arthritic component by an average of 1-2 stages according to Samilson3. The ruptures initially classified as repairable on the basis of tendon retraction and muscular atrophy therefore had to be classified as not (or no longer) repairable four years after the initial diagnosis. Despite satisfactory mobility, there was no longer any possibility of joint-preserving therapy for the patients.
With regard to the suturing of transmural rotator cuff tears, the trend is towards an arthroscopic approach, similar to shoulder stabilization. However, taking into account the literature of the last 3 years, no objectifiable advantage of an arthroscopic technique over the conventional open technique or a mini-open approach can be demonstrated. The trend towards pain reduction and improved function in the short-term postoperative interval is proven for less invasive techniques. However, this advantage had already adapted to the open surgical technique 6 months after the operation. Within arthroscopic techniques, reconstructions using two rows of sutures (“double-row” or “transosseous equivalent”) are increasingly being propagated. But what is the advantage of this technique?
However, these biomechanical advantages cannot be proven on the basis of initial clinical studies. For example, some authors5 found no significant difference in terms of postoperative shoulder function or tendon integrity monitored by magnetic resonance imaging in a randomized comparative study of the arthroscopic 2-row and 1-row technique. Current meta-analyses confirm these results. The question of the time to complete improvement in shoulder function after rotator cuff suture shows that after arthroscopic rotator cuff suture, shoulder function does not reach its final level until 12 months after the operation. The patients were examined in the study at intervals of 3, 6, 12 and 24 months after the operation. The greatest improvements in shoulder function were seen up to the 3rd and from the 3rd to the 6th postoperative month. With regard to active mobility and strength, the development was delayed compared to the overall function and showed the maximum progress around the 6th post-operative month.
A significant step forward in rotator cuff surgery is the so-called superior capsule reconstruction. In this operation, a tight tendon implant is inserted and functions as an abutment to prevent the humeral head from kicking up.6 Pain reduction and functional improvements have been recorded, but no reliable statement can yet be made about the sustainability. Compared to joint replacement, this method performs significantly better, as an implanted endoprosthesis can only be replaced with a new endoprosthesis. And in tendon surgery, this should be aimed for as late as possible...
WERNER, C. M. et al. The biomechanical role of the subscapularis in latissimus dorsi transfer for the treatment of irreparable rotator cuff tears. J Shoulder Elbow Surg, v. 15, n. 6, p. 736-42, 2006 Nov-Dec 2006. ISSN 1532-6500. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/17126245 >.
ZINGG, P. O. et al. Clinical and structural outcomes of nonoperative management of massive rotator cuff tears. J Bone Joint Surg Am, v. 89, n. 9, p. 1928-34, Sep 2007. ISSN 0021-9355. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/17768188 >.
SAMILSON, R. L.; BINDER, W. F. Symptomatic full thickness tears of rotator cuff. An analysis of 292 shoulders in 276 patients. Orthop Clin North Am, v. 6, n. 2, p. 449-66, Apr 1975. ISSN 0030-5898. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/1093091 >.
ERNSTBRUNNER, L. et al. Long-Term Outcomes of Pectoralis Major Transfer for the Treatment of Irreparable Subscapularis Tears: Results After a Mean Follow-up of 20 Years. J Bone Joint Surg Am, v. 101, n. 23, p. 2091-2100, Dec 2019. ISSN 1535-1386. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/31800422 >.
FRANCESCHI, F. et al. Equivalent clinical results of arthroscopic single-row and double-row suture anchor repair for rotator cuff tears: a randomized controlled trial. Am J Sports Med, v. 35, n. 8, p. 1254-60, Aug 2007. ISSN 0363-5465. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/17554104 >.
ALTINTAS, B. et al. Superior Capsule Reconstruction for Irreparable Massive Rotator Cuff Tears: Does It Make Sense? A Systematic Review of Early Clinical Evidence. Am J Sports Med, p. 363546520904378, Mar 2020. ISSN 1552-3365. Disponível em: < https://www.ncbi.nlm.nih.gov/pubmed/32191494 >.
Dr. Martin Schwarz, MSc, Prim. a.D.
Specialist for trauma surgery,
Specialist in Orthopedics and Traumatology Shoulder Center Vienna
Surgery for shoulder, knee and sports injuries