Arthroscopic staple capsulorrhaphy for anterior shoulder instability LARRY
FRCS(C),
COUGHLIN,*† MD, FRCS(C), FACS, MITCH RUBINOVICH,* MD, FRCS(C), BRAD WHITE,‡ MD, FRCS(C), AND JEFFREY GREENSPOON,§ MD, FRCS(C)
JOYCE JOHANSSON,* MD,
From the *Queen Elizabeth
Hospital, Montreal, Quebec, Canada, ‡Nassau-Orthopedic Surgeons, Levittown, New York, and the §Space Coast Orthopaedic Centre, Cocoa Beach, Florida
ABSTRACT
MATERIALS AND METHODS
We reviewed the results of the arthroscopic staple capsulorrhaphy on 47 patients with a followup of 4 years. Thirty-four of the 47 shoulders had a history of traumatic dislocation, while the remaining 13 had a history of subluxation. The recurrence rate was 25%, with 8 shoulders developing recurrent frank dislocation and 4 developing subluxation. Only 21 of the 47 patients were able to resume normal sporting activities after surgical repair. We had no cases of staple loosening within the joint, but we did have 3 patients whose staples were removed because of persistent pain in the
Between shoulder
July 1985 and June 1987, 57 cases of arthroscopic stapling using the technique espoused by Lanny Johnson, which involves securing the labral capsular mechanism using one or two staples, were performed at the Queen Elizabeth Hospital (Fig. 1). The number of staples used at surgery was determined by the size of the Bankart lesion or the amount of capsular redundancy. The maximum number
shoulder.
Anterior
instability of the shoulder continues to be a therapeutic challenge to the orthopaedic surgeon. There are many surgical procedures available that can help the surgeon effectively manage the problem of instability. However, these procedures have not met with great success in allowing throwing athletes to return to their previous level of sporting activity.7,12,14 Anterior instability is the result of laxity of the anterior capsular ligaments, particularly the inferior glenohumeral ligament. This ligament may become attenuated, or may become avulsed by itself or with the labral tissue (Bankart lesion). Using the technique of shoulder arthroscopy, one is better able to identify these lesions.1,6,8 Arthroscopically, the anterior labral capsular mechanism can be reattached and advanced through the use of sutures, staples, or specialized screws2,4,5,9,16 to correct glenohumeral instability. t Address reprint and correspondence requests to: Larry Coughlin, MD, FRCS(C), FACS, Queen Elizabeth Hospital, 2100 Marlowe Avenue, Montreal,
Figure 1. Radiograph showing
Quebec H4A 3L6, Canada.
253
correct
placement of staples.
254
used was 3 (4 cases). The majority had 1 staple (29 cases), while 14 had 2 staples. In the cases where there was no Bankart lesion, the capsule was mobilized and advanced and attached to the glenoid with a staple(s). Forty-seven patients were available for followup (average followup, 4 years; range, 1 to 4.5) and are the basis for this report. There were 38 male and 9 female patients. At the time of first dislocation, the patients ranged in age from 13 to 38 years (average, 21.4). At the time of surgery, the age range was 16 to 56 years (average, 25.3). Twenty-four of the 47 shoulders were on the dominant side. There were 25 right shoulders and 22 left shoulders. Thirty-four of the 47 pa-
tients had
a history of traumatic dislocation requiring a medical or paramedical reduction. The remaining 13 patients had a history of subluxation. There were no cases of voluntary dislocation, nor were there any cases of multidirectional instability. The most common complaint among the population was the inability to participate in sports; 29 stated that this was their primary reason for seeking medical attention. Fourteen patients stated that their main concern was difficulty with daily living activity, while 4 stated that their problem was
pain. After surgery, the patients were immobilized for a period of 3 weeks. After this time, progressive, assisted mobilization of the shoulder was allowed under the direction of a physiotherapist. Once pain-free range of motion was achieved, a program of progressive rotator cuff strengthening exercises using free weights was instituted. At 3 months, patients were encouraged to resume noncontact sporting activity. We encouraged patients involved in contact sports to refrain from participation for 6 months after the time of surgery.
RESULTS At arthroscopy, it was noted that 24 patients had a HillSachs lesion. Mild degenerative articular changes were found in 9 patients. Thirty-one of 34 shoulders in the dislocation group had a Bankart-type lesion, while 6 of the 13 shoulders in the subluxation group had a Bankart lesion. One shoulder was found to have a small rotator cuff tear at the supraspinatus insertion site that was less than 1 cm in size. Eight had a labral tear in the posterior inferior quadrant at the 7 0’ clock position. There were 4 cases with an anterior glenoid rim fracture and all were in the dislocation group (Table 1). These were all old fractures measuring less than 20% of the rim circumference. They had all healed back to the glenoid with some degree of displacement. No attempt TABLE1
made to mobilize and reposition the bony fragment. In these cases, the labral capsular abnormality was addressed and stapled onto the glenoid rim. Postoperative range of motion was compared to the preoperative range. In 18 cases there was no clinical detectable loss of motion. After surgery, 23 shoulders had a decrease of 25% of external rotation. Six shoulders had a loss of more than 50% of the external rotation and a loss of 25% of elevation. At the follow-up examination, patients were rated in terms of stability. Twelve patients developed a recurrent instability. Eight of these patients presented with frank dislocation and 4 with complaints of subluxation. The time of a recurrance of instability after surgery ranged from 9 to 30 months (average, 13.5). Ten of the 12 patients developed their recurrent instability secondary to traumatic injury, usually while involved in high-energy contact sports, such as football and hockey. When we compared subluxation results versus dislocation we found that 7 of the 13 shoulders with a history of subluxation (53.8%) developed recurrent instability, while 5 of the 34 shoulders with a history of dislocation (14.7%) was
developed recurrent instability. In the subluxation group, only one of the seven shoulders had a Bankart lesion, while in the dislocation group four of five shoulders had a Bankart lesion. All of the shoulders that redislocated had a Hill-Sachs lesion, while four of the shoulders that subluxated and continued to be unstable had a Hill-Sachs lesion. After surgery, 21 of the 47 patients had no complaints and were able to resume their normal life and sporting activities. Five complained of mild difficulty trying to resume any type of throwing or racket sport. Eight patients had difficulty with throwing sports that required them to cease participation. The results of 13 patients were rated as poor; these patients stated that, since their surgery, they had to significantly modify their lifestyle because of persistent pain and shoulder problems. The results were rated according to the Carter Rowe scale as shown in Table 2. Considering poor results as failures, good results as fair, and excellent results as successful, the overall success rate of the procedure was 55%. The rate of recurrent instability was 25%. Our results showed that the patients with a history of traumatic dislocation did better than those with a history of subluxation. Seven of 13 patients with a history of subluxation (53.8%) and 5 of the 34 patients with dislocation (14.7%) developed recurrent insta-
bility. A total of 16 patients have undergone a second operation after their initial arthroscopic shoulder surgery. Twelve
Arthroscopic findings
TABLE 2
Overall
score
(Carter-Rowe)
255
patients underwent further surgery because of recurrent instability. At that time, the staple was found to have amputated the Bankart lesion in 3 cases and cut through the capsule in 1 case. Another 3 operations were done because of persistent postoperative pain thought to be caused by problems with the staple. In these 3 patients, the staple was found to be riding somewhat high in the anterior glenoid rim. The staple was removed from all three shoulders. At the time of removal, it was noted that the labral capsular mechanism had healed back onto the glenoid rim and the shoulder under anaesthesia
was
stable. One
patient
developed a late impingement-type syndrome and 18 months after surgery underwent arthroscopic acromioplasty, which relieved the symptoms.
tunately, we have had no serious complications from the use of metal, but we did have to remove staples from three patients because of persistent pain that was thought to be caused by the staples being improperly placed. Comparing our results to those of other arthroscopic procedures for anterior instability of the shoulder, our redislocation rate is higher. Matthews’ had a recurrence rate of 8.3%, while Hawkins4 reported a recurrence rate of 16%. The initial 100 cases of Johnson (L. Johnson, personal communication, 1988) had a redislocation rate of 15%, but he attributed this to too short a period of immobilizaton. His subsequent redislocation rate has been reported between 3% and 4%. Sweeney (H. Sweeney, personal communication, 1987) reported on 38 shoulders treated with an arthroscopic stapling technique, in which there were 4 bonafide redislo-
DISCUSSION
cations. There
The results of arthroscopic stapling for anterior instability of the shoulder do not compare favorably with the results of open surgical repair, as far as controlling recurrence. In our experience, this procedure has not been as successful as the authors had hoped in returning the throwing athlete to sports. Recurrences invariably happened secondary to repeated trauma from contact sports (Table 3). The techniques used in this procedure adhere to the principles of adequate preparation of the gleniod rim, and accurate visualization of the staple while attaching the labral or capsular mechanism onto the glenoid rim, using one or two staples. We also made certain to release the traction before inserting the staple(s). A 3-week period of immobilization after surgery was instituted for all patients. This procedure had the best results when it was done on patients with unidirectional instability with a bonafide Bankart-type lesion. We would not recommend it for patients engaged in throwing, racket, or contact sports. Advantages of this technique over open surgical repair are similar to the advantages found with other arthroscopic procedures. Complications from shoulder arthroscopy have been well described.1,3,12,16 The main complication of this procedure is recurrence. The potential complication arising from the use of metal in open procedures has been well described. For-
management of anterior shoulder instability using various
TABLE 3 Recurrences of instability
°
S, shoulders that subluxated; Dis, shoulders that dislocated.
suture
of
are
other
arthroscopic procedures proposed
for
techniques.&dquo; These techniques do not require the use
metal; however, they do have drawbacks that involve
potential injury to the suprascapular nerve and problems of tying sutures over soft tissue posteriorly.17 Morgan and Bodenstab’o reported on a series of 153 cases in which there was a recurrence rate of 5.2% using suture techniques. Perhaps as these techniques become further refined, the problem of recurrent instability of the shoulder will be improved, allowing a safer and faster return to’sport. CONCLUSIONS In
experience, arthroscopic staple capsulorrhaphy has proved to be as successful as we hoped. It has a higher recurrence rate than open procedures3 and has not proved any more effective in returning the competitive thrower or racket player to their sport. Shoulder arthroscopy, when combined with an examination under arthroscopy, does give the surgeon an overall assessment of the problematic shoulder. It allows a surgeon to detect posterior-inferior quadrant our
not
labral lesions, which are often found in association with anterior instability and can be attended to arthroscopically. Based on our results, we feel that arthroscopic surgery for management of anterior shoulder instability gave better results for recurrent anterior shoulder dislocation than for recurrent anterior shoulder subluxation. The recurrence of shoulder instability after arthroscopic surgical correction was 14.7% for the dislocations versus 53.8% for the subluxations. One might speculate that there is more of a capsular redundancy or inefficiency in patients with a history of subluxation and that the stapling procedure is not able to adequately address the problem. This subject is certain to generate further interest and controversy among orthopaedic surgeons concerned with management of the unstable shoulder. However, our results leave us with serious reservations that arthroscopic staple capsulorraphy is the procedure of choice in the surgical management of the unstable shoulder.
256
REFERENCES 1. Andrews JR, Carson WG, Ortega K: Arthroscopy of the shoulder: Technique and normal anatomy. Am J Sports Med 12: 1-7, 1984 2. Gross RM: Arthroscopic shoulder capsulorraphy: Does it work? Am J Sports Med 17: 495-500, 1989 3. Hastings DE, Coughlin LP: Recurrent subluxation of the glenohumeral joint. Am J Sports Med 9: 352-355, 1981 4. Hawkins RB: Arthroscopic stapling repair for shoulder instability. A retrospective study of 50 cases. J Arthroscopy 5: 122-128, 1989 5. Henderson WD: Arthroscopic stabilization of the anterior shoulder. Clin
Sports Med 6: 581-586, 1987 6. Johnson LL: The shoulder joint. An arthroscopist’s perspective of anatomy and pathology. Clin Orthop 223: 113-125, 1987 7. Lombardo SJ, Kerlan RK, Jobe FW, et al: The modified Bristow procedure for recurrent dislocation of the shoulder. J Bone Joint Surg 58A: 256-261, 1976 8. Matthews LS: Anterior staple capsulorrhaphy for recurrent anterior shoulder instability. Arthroscopy 1: 106-111, 1988 9. Matthews LS, Zarins B, Micheal RH, et al: Anterior portal selection for shoulder arthroscopy. Arthroscopy 1 : 33-39, 1985 (1)
10.
Morgan CD, Bodenstab AB: Arthroscopic Bankart suture repair: Technique and early results. Arthroscopy 3 (2): 111-122, 1987
11. Norwood LA, Fowler HL: Rotator cuff tears. A shoulder arthroscopy complication. Am J Sports Med 17: 837-841, 1989 12. Regan WD, Webster-Bogaert S, Hawkins RJ, et al: Comparative functional analysis of the Bristow, Magnuson-stack, and Putti-Platt procedures for recurrent dislocation of the shoulder. Am J Sports Med 17: 42-48, 1989 13. Rockwood JR, Green DP (eds): Anterior subluxation and dislocation, in Fractures in Adults. Second edition. Philadelphia, JB Lippincott, 1984, p 778 14. Rowe CR, Patel D, Southmayd WW: The Bankart procedure-a long-term end-result study. J Bone Joint Surg 60A: 1-16, 1978 15. Small NC, Chairman, Committee on Complications of the Arthroscopy Association of North America. Complications in Arthroscopy-The Knee and Other Joints. Arthroscopy 2: 253-359, 1986 16. Turkel SJ, Panio MW, Marshall JL, et al: Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg 63A:
1208-1217,1981 17. Zuckerman JD, Matsen FA: Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg 66A: 175-
180, 1984
FRCS(C),
COUGHLIN,*† MD, FRCS(C), FACS, MITCH RUBINOVICH,* MD, FRCS(C), BRAD WHITE,‡ MD, FRCS(C), AND JEFFREY GREENSPOON,§ MD, FRCS(C)
JOYCE JOHANSSON,* MD,
From the *Queen Elizabeth
Hospital, Montreal, Quebec, Canada, ‡Nassau-Orthopedic Surgeons, Levittown, New York, and the §Space Coast Orthopaedic Centre, Cocoa Beach, Florida
ABSTRACT
MATERIALS AND METHODS
We reviewed the results of the arthroscopic staple capsulorrhaphy on 47 patients with a followup of 4 years. Thirty-four of the 47 shoulders had a history of traumatic dislocation, while the remaining 13 had a history of subluxation. The recurrence rate was 25%, with 8 shoulders developing recurrent frank dislocation and 4 developing subluxation. Only 21 of the 47 patients were able to resume normal sporting activities after surgical repair. We had no cases of staple loosening within the joint, but we did have 3 patients whose staples were removed because of persistent pain in the
Between shoulder
July 1985 and June 1987, 57 cases of arthroscopic stapling using the technique espoused by Lanny Johnson, which involves securing the labral capsular mechanism using one or two staples, were performed at the Queen Elizabeth Hospital (Fig. 1). The number of staples used at surgery was determined by the size of the Bankart lesion or the amount of capsular redundancy. The maximum number
shoulder.
Anterior
instability of the shoulder continues to be a therapeutic challenge to the orthopaedic surgeon. There are many surgical procedures available that can help the surgeon effectively manage the problem of instability. However, these procedures have not met with great success in allowing throwing athletes to return to their previous level of sporting activity.7,12,14 Anterior instability is the result of laxity of the anterior capsular ligaments, particularly the inferior glenohumeral ligament. This ligament may become attenuated, or may become avulsed by itself or with the labral tissue (Bankart lesion). Using the technique of shoulder arthroscopy, one is better able to identify these lesions.1,6,8 Arthroscopically, the anterior labral capsular mechanism can be reattached and advanced through the use of sutures, staples, or specialized screws2,4,5,9,16 to correct glenohumeral instability. t Address reprint and correspondence requests to: Larry Coughlin, MD, FRCS(C), FACS, Queen Elizabeth Hospital, 2100 Marlowe Avenue, Montreal,
Figure 1. Radiograph showing
Quebec H4A 3L6, Canada.
253
correct
placement of staples.
254
used was 3 (4 cases). The majority had 1 staple (29 cases), while 14 had 2 staples. In the cases where there was no Bankart lesion, the capsule was mobilized and advanced and attached to the glenoid with a staple(s). Forty-seven patients were available for followup (average followup, 4 years; range, 1 to 4.5) and are the basis for this report. There were 38 male and 9 female patients. At the time of first dislocation, the patients ranged in age from 13 to 38 years (average, 21.4). At the time of surgery, the age range was 16 to 56 years (average, 25.3). Twenty-four of the 47 shoulders were on the dominant side. There were 25 right shoulders and 22 left shoulders. Thirty-four of the 47 pa-
tients had
a history of traumatic dislocation requiring a medical or paramedical reduction. The remaining 13 patients had a history of subluxation. There were no cases of voluntary dislocation, nor were there any cases of multidirectional instability. The most common complaint among the population was the inability to participate in sports; 29 stated that this was their primary reason for seeking medical attention. Fourteen patients stated that their main concern was difficulty with daily living activity, while 4 stated that their problem was
pain. After surgery, the patients were immobilized for a period of 3 weeks. After this time, progressive, assisted mobilization of the shoulder was allowed under the direction of a physiotherapist. Once pain-free range of motion was achieved, a program of progressive rotator cuff strengthening exercises using free weights was instituted. At 3 months, patients were encouraged to resume noncontact sporting activity. We encouraged patients involved in contact sports to refrain from participation for 6 months after the time of surgery.
RESULTS At arthroscopy, it was noted that 24 patients had a HillSachs lesion. Mild degenerative articular changes were found in 9 patients. Thirty-one of 34 shoulders in the dislocation group had a Bankart-type lesion, while 6 of the 13 shoulders in the subluxation group had a Bankart lesion. One shoulder was found to have a small rotator cuff tear at the supraspinatus insertion site that was less than 1 cm in size. Eight had a labral tear in the posterior inferior quadrant at the 7 0’ clock position. There were 4 cases with an anterior glenoid rim fracture and all were in the dislocation group (Table 1). These were all old fractures measuring less than 20% of the rim circumference. They had all healed back to the glenoid with some degree of displacement. No attempt TABLE1
made to mobilize and reposition the bony fragment. In these cases, the labral capsular abnormality was addressed and stapled onto the glenoid rim. Postoperative range of motion was compared to the preoperative range. In 18 cases there was no clinical detectable loss of motion. After surgery, 23 shoulders had a decrease of 25% of external rotation. Six shoulders had a loss of more than 50% of the external rotation and a loss of 25% of elevation. At the follow-up examination, patients were rated in terms of stability. Twelve patients developed a recurrent instability. Eight of these patients presented with frank dislocation and 4 with complaints of subluxation. The time of a recurrance of instability after surgery ranged from 9 to 30 months (average, 13.5). Ten of the 12 patients developed their recurrent instability secondary to traumatic injury, usually while involved in high-energy contact sports, such as football and hockey. When we compared subluxation results versus dislocation we found that 7 of the 13 shoulders with a history of subluxation (53.8%) developed recurrent instability, while 5 of the 34 shoulders with a history of dislocation (14.7%) was
developed recurrent instability. In the subluxation group, only one of the seven shoulders had a Bankart lesion, while in the dislocation group four of five shoulders had a Bankart lesion. All of the shoulders that redislocated had a Hill-Sachs lesion, while four of the shoulders that subluxated and continued to be unstable had a Hill-Sachs lesion. After surgery, 21 of the 47 patients had no complaints and were able to resume their normal life and sporting activities. Five complained of mild difficulty trying to resume any type of throwing or racket sport. Eight patients had difficulty with throwing sports that required them to cease participation. The results of 13 patients were rated as poor; these patients stated that, since their surgery, they had to significantly modify their lifestyle because of persistent pain and shoulder problems. The results were rated according to the Carter Rowe scale as shown in Table 2. Considering poor results as failures, good results as fair, and excellent results as successful, the overall success rate of the procedure was 55%. The rate of recurrent instability was 25%. Our results showed that the patients with a history of traumatic dislocation did better than those with a history of subluxation. Seven of 13 patients with a history of subluxation (53.8%) and 5 of the 34 patients with dislocation (14.7%) developed recurrent insta-
bility. A total of 16 patients have undergone a second operation after their initial arthroscopic shoulder surgery. Twelve
Arthroscopic findings
TABLE 2
Overall
score
(Carter-Rowe)
255
patients underwent further surgery because of recurrent instability. At that time, the staple was found to have amputated the Bankart lesion in 3 cases and cut through the capsule in 1 case. Another 3 operations were done because of persistent postoperative pain thought to be caused by problems with the staple. In these 3 patients, the staple was found to be riding somewhat high in the anterior glenoid rim. The staple was removed from all three shoulders. At the time of removal, it was noted that the labral capsular mechanism had healed back onto the glenoid rim and the shoulder under anaesthesia
was
stable. One
patient
developed a late impingement-type syndrome and 18 months after surgery underwent arthroscopic acromioplasty, which relieved the symptoms.
tunately, we have had no serious complications from the use of metal, but we did have to remove staples from three patients because of persistent pain that was thought to be caused by the staples being improperly placed. Comparing our results to those of other arthroscopic procedures for anterior instability of the shoulder, our redislocation rate is higher. Matthews’ had a recurrence rate of 8.3%, while Hawkins4 reported a recurrence rate of 16%. The initial 100 cases of Johnson (L. Johnson, personal communication, 1988) had a redislocation rate of 15%, but he attributed this to too short a period of immobilizaton. His subsequent redislocation rate has been reported between 3% and 4%. Sweeney (H. Sweeney, personal communication, 1987) reported on 38 shoulders treated with an arthroscopic stapling technique, in which there were 4 bonafide redislo-
DISCUSSION
cations. There
The results of arthroscopic stapling for anterior instability of the shoulder do not compare favorably with the results of open surgical repair, as far as controlling recurrence. In our experience, this procedure has not been as successful as the authors had hoped in returning the throwing athlete to sports. Recurrences invariably happened secondary to repeated trauma from contact sports (Table 3). The techniques used in this procedure adhere to the principles of adequate preparation of the gleniod rim, and accurate visualization of the staple while attaching the labral or capsular mechanism onto the glenoid rim, using one or two staples. We also made certain to release the traction before inserting the staple(s). A 3-week period of immobilization after surgery was instituted for all patients. This procedure had the best results when it was done on patients with unidirectional instability with a bonafide Bankart-type lesion. We would not recommend it for patients engaged in throwing, racket, or contact sports. Advantages of this technique over open surgical repair are similar to the advantages found with other arthroscopic procedures. Complications from shoulder arthroscopy have been well described.1,3,12,16 The main complication of this procedure is recurrence. The potential complication arising from the use of metal in open procedures has been well described. For-
management of anterior shoulder instability using various
TABLE 3 Recurrences of instability
°
S, shoulders that subluxated; Dis, shoulders that dislocated.
suture
of
are
other
arthroscopic procedures proposed
for
techniques.&dquo; These techniques do not require the use
metal; however, they do have drawbacks that involve
potential injury to the suprascapular nerve and problems of tying sutures over soft tissue posteriorly.17 Morgan and Bodenstab’o reported on a series of 153 cases in which there was a recurrence rate of 5.2% using suture techniques. Perhaps as these techniques become further refined, the problem of recurrent instability of the shoulder will be improved, allowing a safer and faster return to’sport. CONCLUSIONS In
experience, arthroscopic staple capsulorrhaphy has proved to be as successful as we hoped. It has a higher recurrence rate than open procedures3 and has not proved any more effective in returning the competitive thrower or racket player to their sport. Shoulder arthroscopy, when combined with an examination under arthroscopy, does give the surgeon an overall assessment of the problematic shoulder. It allows a surgeon to detect posterior-inferior quadrant our
not
labral lesions, which are often found in association with anterior instability and can be attended to arthroscopically. Based on our results, we feel that arthroscopic surgery for management of anterior shoulder instability gave better results for recurrent anterior shoulder dislocation than for recurrent anterior shoulder subluxation. The recurrence of shoulder instability after arthroscopic surgical correction was 14.7% for the dislocations versus 53.8% for the subluxations. One might speculate that there is more of a capsular redundancy or inefficiency in patients with a history of subluxation and that the stapling procedure is not able to adequately address the problem. This subject is certain to generate further interest and controversy among orthopaedic surgeons concerned with management of the unstable shoulder. However, our results leave us with serious reservations that arthroscopic staple capsulorraphy is the procedure of choice in the surgical management of the unstable shoulder.
256
REFERENCES 1. Andrews JR, Carson WG, Ortega K: Arthroscopy of the shoulder: Technique and normal anatomy. Am J Sports Med 12: 1-7, 1984 2. Gross RM: Arthroscopic shoulder capsulorraphy: Does it work? Am J Sports Med 17: 495-500, 1989 3. Hastings DE, Coughlin LP: Recurrent subluxation of the glenohumeral joint. Am J Sports Med 9: 352-355, 1981 4. Hawkins RB: Arthroscopic stapling repair for shoulder instability. A retrospective study of 50 cases. J Arthroscopy 5: 122-128, 1989 5. Henderson WD: Arthroscopic stabilization of the anterior shoulder. Clin
Sports Med 6: 581-586, 1987 6. Johnson LL: The shoulder joint. An arthroscopist’s perspective of anatomy and pathology. Clin Orthop 223: 113-125, 1987 7. Lombardo SJ, Kerlan RK, Jobe FW, et al: The modified Bristow procedure for recurrent dislocation of the shoulder. J Bone Joint Surg 58A: 256-261, 1976 8. Matthews LS: Anterior staple capsulorrhaphy for recurrent anterior shoulder instability. Arthroscopy 1: 106-111, 1988 9. Matthews LS, Zarins B, Micheal RH, et al: Anterior portal selection for shoulder arthroscopy. Arthroscopy 1 : 33-39, 1985 (1)
10.
Morgan CD, Bodenstab AB: Arthroscopic Bankart suture repair: Technique and early results. Arthroscopy 3 (2): 111-122, 1987
11. Norwood LA, Fowler HL: Rotator cuff tears. A shoulder arthroscopy complication. Am J Sports Med 17: 837-841, 1989 12. Regan WD, Webster-Bogaert S, Hawkins RJ, et al: Comparative functional analysis of the Bristow, Magnuson-stack, and Putti-Platt procedures for recurrent dislocation of the shoulder. Am J Sports Med 17: 42-48, 1989 13. Rockwood JR, Green DP (eds): Anterior subluxation and dislocation, in Fractures in Adults. Second edition. Philadelphia, JB Lippincott, 1984, p 778 14. Rowe CR, Patel D, Southmayd WW: The Bankart procedure-a long-term end-result study. J Bone Joint Surg 60A: 1-16, 1978 15. Small NC, Chairman, Committee on Complications of the Arthroscopy Association of North America. Complications in Arthroscopy-The Knee and Other Joints. Arthroscopy 2: 253-359, 1986 16. Turkel SJ, Panio MW, Marshall JL, et al: Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg 63A:
1208-1217,1981 17. Zuckerman JD, Matsen FA: Complications about the glenohumeral joint related to the use of screws and staples. J Bone Joint Surg 66A: 175-
180, 1984
