Background: Both arthroscopic and open surgical repairs are utilized
for the management of anterior glenohumeral instability. To determine the
evidence supporting the relative effectiveness of these two approaches, we
conducted a rigorous and comprehensive analysis of all reports comparing
arthroscopic and open repairs.
Methods: A systematic analysis of eighteen published or presented
studies was performed to determine if there were significant differences
between the two approaches with regard to recurrence (recurrent dislocation,
subluxation, and/or apprehension and/or a reoperation for instability), return
to work and/or sports, and Rowe scores. We also performed subgroup analysis to
determine if the quality of the study or the arthroscopic technique influenced
the results.
Results: We identified four randomized controlled trials, ten
controlled clinical trials, and four other comparative studies. Results were
influenced both by the quality of the study and by the arthroscopic technique.
Meta-analysis revealed that, compared with open methods, arthroscopic repairs
were associated with significantly higher risks of recurrent instability (p
< 0.00001, relative risk = 2.37, 95% confidence interval = 1.66 to 3.38),
recurrent dislocation (p < 0.0001, relative risk = 2.74, 95% confidence
interval = 1.75 to 4.28), and a reoperation (p = 0.002, relative risk = 2.32,
95% confidence interval = 1.35 to 3.99). When considered alone, arthroscopic
suture anchor techniques were associated with significantly higher risks of
recurrent instability (p = 0.01, relative risk = 2.25, 95% confidence interval
= 1.21 to 4.17) and recurrent dislocation (p = 0.004, relative risk = 2.57,
95% confidence interval = 1.35 to 4.92) than were open methods. Arthroscopic
approaches were also less effective than open methods with regard to enabling
patients to return to work and/or sports (p = 0.03, relative risk = 0.87, 95%
confidence interval = 0.77 to 0.99). On the other hand, analysis of the
randomized clinical trials indicated that arthroscopic repairs were associated
with higher Rowe scores (p = 0.002, standardized mean difference = 0.43, 95%
confidence interval = 0.16 to 0.70) than were open methods. Similarly,
analysis of the arthroscopic suture anchor techniques alone showed the Rowe
scores to be higher (p = 0.04, standardized mean difference = 0.29, 95%
confidence interval = 0.01 to 0.56) than those associated with open
methods.
Conclusions: The available evidence indicates that arthroscopic
approaches are not as effective as open approaches in preventing recurrent
instability or enabling patients to return to work. Arthroscopic approaches
resulted in better function as reflected by the Rowe scores in the randomized
clinical trials. The study design and the arthroscopic technique had
substantial effects on the results of the analysis.
Level of Evidence: Therapeutic Level II. See Instructions
to Authors for a complete description of levels of evidence.