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Upper Limb: E. Calvo, J. J. Granizo, and D. Fernández-Yruegas Criteria for arthroscopic treatment of anterior instability of the shoulder: A PROSPECTIVE STUDY J Bone Joint Surg Br 2005; 87-B: 677-683 [Abstract] [Full text] [PDF]

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Reply to Sexton and Ricketts

Emilio Calvo, Juan J. Granizo, and D Fernandez-Yruegas   (15 June 2005)

Criteria for arthroscopic treatment of anterior instability of the shoulder

Shaun A Sexton, David M. Ricketts and Christopher Pearce.   (23 May 2005)

Reply to Sexton and Ricketts 15 June 2005
Emilio Calvo, MD, Consultant Orthopaedic Surgeon Department of Orthopaedic Surgery. Fundacion Jimenez Diaz. Madrid, SPAIN, Juan J. Granizo, and D Fernandez-Yruegas Send letter to journal: Re: Reply to Sexton and Ricketts ecalvo{at}fjd.es Emilio Calvo, et al.	Sir, We thank Messrs Sexton and Ricketts for their interest in our article. There is clearly enthusiasm for the arthroscopic treatment of shoulder instability. There is evidence to show that arthroscopy reduces morbidity and that it achieves a better cosmetic result, as well as a better overall range of movement and function.1,2 These benefits are confirmed by patients. The degree of patient satisfaction in our study was very high, even in those cases where there was recurrent post-operative instability. Our criteria of failure were strict, and the majority of patients in whom the procedure was considered to have failed had improved their level of stability sufficiently so as not to interfere with their activities. In spite of these advantages, the major drawback of arthroscopic shoulder stabilisation is its higher recurrence rate in comparison with open surgery. Technical improvements, the repair of all joint abnormalities potentially contributing to instability and the proper selection of candidates are key issues in improving results. Kim et al3 and Garstman, Roddey and Hammerman4 reported recurrence rates comparable with open techniques using bone anchors and addressing all intra-articular pathology. In our series only long-term cases, operated on with the multiple suture technique, were included in order to make the patient series homogeneous. Therefore, the figure 18% should not be considered the usual recurrence rate of arthroscopic shoulder stabilisation. Regarding patient selection, our study establishes a clear system to improve the results of arthroscopic shoulder stabilisation. Arthroscopy has achieved a high level of acceptance, and enthusiasm for its application in shoulder instability is based on clinical evidence. It is our responsibility as orthopaedic surgeons to do our best to improve the results. E. CALVO, MD D. FERNÁNDEZ-YRUEGAS, MD J. J. GRANIZO, MD Fundación Jiménez Diaz, Madrid, Spain. 1. Green MR, Christensen KP. Arthroscopic versus open Bankart procedures: A comparison of early morbidity and complications. Arthroscopy 1993;9:371-4. 2. Karlsson J, Magnusson L, Ejerhed L, et al. Comparison of open and arthroscopic stabilization for recurrent shoulder dislocation in patients with a Bankart lesion. Am J Sports Med 2001;29:538-42. 3. Kim SH, Ha KI, Cho YB, Ryu BD, Oh I. Arthroscopic anterior stabilization of the shoulder: two to six-year follow-up. J Bone Joint Surg [Am] 2003;85-A:1511-18. 4. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability: two to five-year follow-up. J Bone Joint Surg [Am] 2000;82:991-1003.
Criteria for arthroscopic treatment of anterior instability of the shoulder 23 May 2005
Shaun A Sexton, Specialist Registrar Princess Royal Hospital, Haywards Heath, UK, David M. Ricketts and Christopher Pearce. Send letter to journal: Re: Criteria for arthroscopic treatment of anterior instability of the shoulder shaunsexton{at}doctors.org.uk Shaun A Sexton, et al.	Sir, We read this paper with interest and would like to raise the following points. 1. The authors state that 'open techniques have a lower failure rate, but carry a risk of restriction of movement and a longer period of recovery.' However, this rationale in support of arthroscopic surgery is not supported by the evidence and is, in fact, contradicted later in the paper. The study by Pagnani and Dome1 is cited in their discussion. It showed that, in American football players, open surgery can restore stability while maintaining a good range of movement. Calvo et al describe their post- operative regime following arthroscopic surgery. The period of recovery recommended is not shorter than the post-operative regime recommended following open surgery.2 2. The paper documents a recurrence rate of 18%, a figure which is similar to other studies and which the authors admit 'is not acceptable'. This rate is substantially higher than with open repairs which have a recurrence rate of between 6.3% and 11.7%.3 3. Despite the high failure rate of arthroscopic surgery, the authors maintain their enthusiasm for the procedure, stating that it 'has clear advantages in comparison with open surgery' and that 'these objective benefits are supported by the high degree of satisfaction reported by our patients, most of whom recognised that they would choose arthroscopic instead of open stabilisation again, even those with recurrent post-operative instability.' The authors’ enthusiasm for the procedure seems to have communicated itself to the patients, as six patients with recurrent instability still rated their result as good or excellent. We wonder how they would have rated their result had the operation been successful. The authors also state that only one in 65 patients declined arthroscopic surgery at the outset. We feel that the patients’ and doctors’ enthusiasm for arthroscopic shoulder stabilisation is not supported by the evidence. S. A. SEXTON D. M. RICKETTS Princess Royal Hospital, Haywards Heath, UK. 1. Pagnani MJ, Dome DC. Surgical treatment of traumatic shoulder instability in American football players. J Bone Joint Surg [Am] 2002;84-A:711-15. 2. Writh MA, Blatter G, Rockwood CA. The capsular imbrication procedure for recurrent anterior instability of the shoulder. J Bone Joint Surg [Am] 1996;78A:246-59. 3. Robinson CM, Dobson RJ. Anterior instability of the shoulder after trauma. J Bone Joint Surg [Br] 2004;86-B:469.