Shoulder Instability in the Overhead Athlete: A Systematic Review Comparing Arthroscopic and Open Stabilization Procedures

OBJECTIVES: Overhead athletes place extraordinary physiologic demands on the shoulder during athletic activity. Repetitive microtrauma can result in attenuation of important capsuloligamentous structures that are responsible for providing glenohumeral stability resulting in symptomatic instability. Surgical management can utilize either an arthroscopic or open approach to shoulder stabilization; however, there is a paucity of data to support a specific technique and guide surgical decision making in this unique patient population. The purpose of the present study was to determine functional outcomes, including return to play, range of motion (ROM), validated outcome scores and recurrent instability following arthroscopic and open shoulder stabilization in overhead athletes diagnosed with anterior instability. METHODS: MEDLINE and the Cochrane Database of Systematic Reviews were searched. Eleven articles matched our selection criteria for randomized controlled trials in which a cohort of overhead athletes participating in sports including baseball, tennis, volleyball, and freestyle swimming, were surgically treated by capsular plication or Bankart repair through either an open or arthroscopic approach for anterior shoulder subluxation or dislocation. The studies were assessed for methodological quality and relevant data was extracted and further evaluated. Results of comparable groups of trials were pooled and mean differences as well as 95% confidence intervals were calculated for continuous outcomes. A grading schema was designed to assess return to play: return to the same level of play (Grade 1), diminished level of play (Grade 2), and failure to return to play (Grade 3). RESULTS: In overhead athletes with anterior glenohumeral subluxation or dislocation, return to play was similar between arthroscopic and open approaches (Grade 1 = arthroscopic 72 ± 22.6%, open 68.7 ± 7.8%; Grade 2 = arthroscopic 24.2 ± 18.3%, open 34.5 ± 7.8%; Grade 3 = arthroscopic 7.2 ± 10.8%, open 8.3 ± 14.4%). Arthroscopic and open approaches demonstrated similar changes in post-operative ROM, as evaluated through degrees of external rotation (arthroscopic -3.6 ± 1.9o, open -3.9 ± 1.9o), forward flexion (arthroscopic -2 ± 1.4(o) in FF, open -2.7 ± 3.82(o)), abduction (arthroscopic -0.7(o), open -4.6(o)) and internal rotation (arthroscopic -2.7(o), open -2.5(o)). No significant difference in functional score outcomes existed between arthroscopic (UCLA 31.2 ± 2.7, Rowe 87.1 ± 10.3, Constant 80.9 ± 16.4) and open (UCLA 30.8 ± 0.6, Rowe 87.5 ± 6, Constant 77.2 ± 15.3) stabilization. Recurrent instability, defined as either recurrent subluxation or dislocation was significantly higher with arthroscopic (11.4 ± 2.8%) versus open (4 ± 1.4%) stabilization. CONCLUSION: Arthroscopic management of anterior glenohumeral microinstability and overt instability allows overhead athletes to return to the same level of play as open stabilization, with similar levels of post-operative ROM and comparable clinical outcomes as measured by validated outcome scores. The higher rate of recurrent instability in overhead athletes following arthroscopic stabilization is similar to current studies in other athletic cohorts (e.g. contact athletes) and warrants further investigation to determine the reasons for this observation.