Introduction

Arthroscopic methods for the treatment of anterior shoulder instability have several purported advantages over open repairs including smaller incisions, minimal trauma to the subscapularis tendon, less perioperative pain, easier rehabilitation, and better return of motion. With current advances in instrumentation, arthroscopic methods are also often technically easier than traditional open repairs. Given these considerations, one might reasonably ask, “Why shouldn’t every unstable shoulder be repaired via the arthroscope?”

Despite the inherent advantages of arthroscopic stabilization, open stabilization techniques continue to have important places in the armamentarium of the shoulder surgeon. I published my first report on arthroscopic stabilization in 1993 and continue to perform the procedure on properly selected patients. However, it is my belief that arthroscopic stabilization remains an inherently different operation than open stabilization for several reasons:

1. Open methods allow the surgeon to completely free the capsule from the subscapularis to precisely tension the capsule without adherence to the subscapularis.

2. The rotator interval can be better visualized and tensioned via an open technique; open rotator interval closure does not have the same effect in shoulder translation and rotation as arthroscopic closure.¹^,²

3. Capsular thickness can be doubled during the repair, overlapping the capsule with an open repair.

4. The arm can be optimally positioned for open repair.

5. Bony lesions can be addressed more satisfactorily with an open technique.

6. Open techniques allow for repair of the capsule and labrum with the knots tied extra-articularly, reducing the risk of impingement of suture material on the articular surfaces.

With the exception of a high failure rate reported in a series of West Point cadets,³ the results of open stabilization have been uniformly excellent with postoperative recurrence rates generally reported between 0% and 5% (Table 12-1). In this era of evidence-based medicine, three separate meta-analyses have concluded that the results of open stabilization have been superior to those of arthroscopic stabilization.⁸^–¹⁰ Of the four direct comparisons of open versus arthroscopic stabilization currently available in the literature,⁵^,¹¹^–¹³ two⁵^,¹² of the four revealed clear advantages of the open method. In one¹³ of the other two reports, no recurrences were found in either group and a large number of patients were excluded based on the findings of an arthroscopic examination, making interpretation of this study difficult. In the final comparison (again from West Point),¹¹ low recurrence rates were noted in both the open and arthroscopic groups, but mean operative time for the open method was 2½ hours compared with less than an hour for the arthroscopic method, suggesting a difference in the authors’ surgical proficiency with the open technique compared with the arthroscopic method. (Our mean operative time for an open stabilization is less than half that.)

Table 12-1 Results of Open Stabilization

	N	Recurrence Rate
Gill et al⁴	60	5%
Hubbell et al⁵	20	0%
Pagnani et al⁶	58	3%
Uhorchak et al³	66	22%
Wirth et al⁷	142	3%

A concern about the risk of subscapularis rupture after open stabilization has recently been promulgated in two recent reports.¹⁴^,¹⁵ Before the publication of these two series, subscapularis rupture after open stabilization was a reportable case.¹⁶^,¹⁷ These concerns appear to be somewhat overstated. In the series by Sachs et al, only one patient had documented subscapularis insufficiency by magnetic resonance imaging (MRI). In the report by Scheibel et al,¹⁵ no complete ruptures were noted on MRI; instead, a degree of atrophy was noted in the superior portion of the tendon that was largely compensated by hypertrophy of the inferior portion. Clinical insufficiency of the subscapularis after open stabilization is exceedingly rare. We have had no instances after primary stabilization in our practice in 15 years. In two recent analyses of shoulder strength after open versus arthroscopic stabilization, strength was equal between the open and arthroscopic groups at 1 year after surgery.¹⁸^,¹⁹

There remain several possible indications for open stabilization, including the following:

• Instability in the contact athlete

• Bony defects of humeral head or glenoid in association with instability

• Humeral avulsion of the glenohumeral ligaments

• Rupture of the subscapularis in association with primary dislocation

• Failed arthroscopic or open repair

• Atraumatic instability

We consider two of these indications in the following sections.

Contact athletes

The results of arthroscopic stabilization in contact athletes have been generally disappointing with failures rates ranging from 14% to 60%.⁵^,²⁰^–²² Hubbell et al reported no recurrences in contact athletes after open stabilization as compared with a 60% recurrence after arthroscopic stabilization.⁵

Our experience with open stabilization in 58 American football players yielded a 3% recurrence rate (2 with subluxation, no dislocations).⁶ Fifty-two of the 58 athletes returned to their sport with only one discontinuing because of the affected shoulder. Motion loss was minimal after open stabilization.

Bony defects of humeral head/glenoid

High recurrence rates have been reported after arthroscopic Bankart repair in patients with bony defects of the glenoid and humeral head.²⁰^,²³ Burkhart et al²⁰ reported that contact athletes who had an “engaging” Hill-Sachs lesion or “inverted pear” glenoid had a recurrence rate of 67%. Their subdivision of Hill-Sachs lesions into “engaging” and “nonengaging” types is commonly used in contemporary lectures on shoulder instability. Although more recent studies by Sugaya et al²⁴ and Mologne et al²⁵ dispute the contention that high failure rates can be expected after arthroscopic stabilization, it has become accepted in many circles that such lesions increase the risk of failure with arthroscopic capsular repair, and this impression is sometimes generalized to open capsular repair as well.

A review of the few published reports of traditional open capsular repair in the face of defects of the humeral head and/or glenoid reveals that the results have actually been quite good. Rowe et al,¹⁷ in their historic 1978 end-result study of open Bankart repairs, found the postoperative recurrence actually decreased, from 3.5% to 2%, in patients with defects of the glenoid rim. Bigliani et al²⁶ reported a 12% recurrence rate after open capsular shift in patients with glenoid bone loss. Rowe et al¹⁷ found a slight increase in recurrence after open Bankart repair in patients with moderate or severe Hills-Sachs lesions (5% versus 3.5%). Gill et al,⁴^,²⁷ in a more recent series of open Bankart repairs, found that their recurrence rate doubled from 3% to an acceptable 6% in the presence of a large Hill-Sachs lesion.

Despite the historically good results with traditional open stabilization in patients with bony defects of the humeral head and glenoid, a number of bone augmentation procedures have recently been recommended in these patients. However, bony procedures of this type raise several concerns: (1) they do not address capsular laxity or capsulolabral separation, (2) there is a high risk of complications from hardware loosening or nonunion, (3) revision surgery is difficult, and (4) there is a high incidence of postoperative arthrosis.

We recently determined the recurrence rates with a contemporary method of open anterior stabilization without bony augmentation in patients in our practice with defects of the glenoid and/or humeral head.²⁸ The overall recurrence rate was 2% (2/103), with one patient having a postoperative dislocation and the other experiencing subluxation. The recurrence rate in patients with Hill-Sachs lesions was not statistically higher than the overall rate at 2% (2/87). Patients with engaging Hill-Sachs lesions had a 4% recurrence (1/28), but this was not statistically significant. One of the 9 patients (11%) with large defects of the humeral head had a recurrence—again, not statistically significant. There were no recurrences in the 14 patients with glenoid rim deficiency.

Based on the low rates of recurrence, motion loss that was equal to or better than that reported for bone-block procedures and the seemingly self-evident premise that the complication rate of capsular repair alone should be lower than that of capsular repair combined with bone augmentation, it appears that bone-block or grafting procedures are not necessary in the majority of patients with bony defects of the glenoid and/or humeral head who are treated with contemporary techniques of open stabilization.