w w w . r b o . o r g . b r
Original
article
Bankart
arthroscopic
procedure:
comparative
study
on
use
of
double
or
single-thread
anchors
after
a
2-year
follow-up
夽
Glaydson
Gomes
Godinho
∗,
José
Márcio
Alves
Freitas,
Flávio
de
Oliveira
Franc¸a,
Flávio
Márcio
de
Lago
e
Santos,
Alan
Arruda
Aragão,
Marcos
Knoll
Barros
OrthopedicHospitalandLifecenterHospital,BeloHorizonte,MG,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received21November2013 Accepted6January2014
Availableonline31December2014
Keywords:
Jointinstability
Shoulderdislocation/epidemiology Shoulderdislocation/surgery
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s
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c
t
Objective:Tocomparetheuseofanchorswithdoubleandsingle-threadloadinginthe single-rowBankartarthroscopicprocedure.
Methods:252patients(258shoulders)underwentBankartarthroscopicsurgerywith evalua-tionafteraminimumfollow-upof2years.Theyunderwentrepairseitherusinganchorswith singleloadingofahigh-resistancenon-absorbablebraidedthread(206shoulders;groupAS) orusingdoubleloadingofthreadwiththesamecharacteristics(52shoulders;groupAD). ThepatientswereevaluatedusingtheUCLAandCarter-Rowescales.Thepatients’return tosportsactivityandrecurrenceswerealsocompared.
Results:Therewasnosignificantdifferencebetweenthegroupsregardingthesurgicalfailure rate(groupAS5.8%;groupAD7.7%;p=0.62).GroupASpresentedabettermeanCarter-Rowe score(groupAS94.4;groupAD88.6;p<0.05)andgreaterreturntothesamesportslevel (groupAS79.1;groupAD72.1;p<0.05).
Conclusion:Useofanchorswithdoublethreadloadingdidnotshowanyclinicaladvantage forarthroscopicrepairoftraumaticanteriorshoulderinstability,inrelationtouseof single-threadanchors,overa2-yearfollow-up.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Procedimento
artroscópico
de
Bankart:
estudo
comparativo
do
uso
de
âncoras
com
fio
duplo
ou
simples
após
seguimento
de
dois
anos
Palavras-chave:
Instabilidadearticular
Luxac¸ãodoombro/epidemiologia Luxac¸ãodoombro/cirurgia
r
e
s
u
m
o
Objetivo:Compararousodeâncorascomcarregamentoduploecomcarregamentosimples defionoprocedimentoartroscópicodeBankartcomfileirasimples.
Métodos:ForamsubmetidosàcirurgiaartroscópicadeBankarteavaliadosapósseguimento mínimodedoisanos252pacientes(258ombros).Foramsubmetidosareparocomâncoras
夽
WorkdevelopedintheShoulderGroupoftheOrthopedicHospitalandattheLifecenterHospital,BeloHorizonte,MG,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](G.G.Godinho).
http://dx.doi.org/10.1016/j.rboe.2014.12.006
comcarregamentosimplesdefiotranc¸adonãoabsorvíveldealtaresistência206ombros (grupoAS)ecomâncorascomcarregamentoduplocomfiosdemesmascaracterísticas52 (grupoAD).OspacientesforamavaliadossegundoasescalasUCLAeCarter-Rowe.Oretorno àatividadeesportivaearecidivatambémforamcomparados.
Resultados:Nãohouvediferenc¸asignificanteentreosgruposquantoàtaxadefalhacirúrgica (grupoAS5,8%;grupoAD7,7%;p=0,62).OgrupoASapresentoumelhorCarter-Rowemédio (grupoAS94,4;grupoAD88,6;p<0,05)emaiorretornoaomesmonívelesportivo(grupoAS 79,1;grupoAD72,1;p<0,05).
Conclusão: Ousodeâncorascomcarregamentoduplodefiosnãodemonstrouvantagem clínicanoreparoartroscópicodainstabilidadeanteriortraumáticadoombroemrelac¸ãoao usodeâncorassimplesnoseguimentodedoisanos.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Theglenohumeraljointistheonethatmostoftenpresents instabilityinthehumanbody(dislocationandsubluxation), with an incidenceof 17 cases per 100,000 inhabitants per year.1Anteriorinstabilityaccountsforapproximately85%of thecasesoftraumaticdislocation.Thenaturalhistoryofthis pathologicalconditionafterthefirstepisodehasbeenwidely studiedanditisknownthattherearesomeimportantfactors thatinfluencetherecurrencerates,suchasage,involvement incontactsports,magnitudeofthebonedefects,ligament lax-ityandtimeelapsedbetweenthefirstepisodeandsurgery.2–4 Robinsonetal.5foundarecurrencerateof55%after2years, amongpatientsundertheageof35years,withaprobability of86%forpatientsaged15yearsand26%forpatientsaged35 years.
In the past, the elective option for treating traumatic anterior instabilitywas open surgery, even afterthe intro-duction of the arthroscopic technique, given that studies showed that the lattermethod led to a higher recurrence rate.6–8 Laneet al.6 performedarthroscopiccapsulorrhaphy andfoundthattherecurrencerateamongtheir54patients was 33%. In the same year, Grana used the transosseous suture technique that had been introduced by Morgan in 1987 and found that the recurrence rate was 44%.7 In 1997, Godinho et al.8 also used transosseous suturingand foundthattherecurrencerateamongtheir79patientswas 13.9%.
Studies conducted more recently have shown improve-ments in the clinical results from the arthroscopic tech-nique,particularly withregard torecurrence, withrates of 4–18%,2,9–11 i.e. equivalent to those from the open tech-nique. These improvements come from better anatomical knowledgeofthepathologicalcondition,greaterexperience among surgeons and evolution of the arthroscopic mate-rial, especially through the emergence of suture anchors, whichwere introduced byWolf.12 Thechallenge of dimin-ishingthe recurrencerate hasmeantthat improvementof the technique has become an objective. A recent biome-chanical study by Kamath et al.13 showed that using two anchors with double loading provided resistance greater than or equal to the use of three anchors with single threads.
Forthesurgicaltreatmenttobesuccessful,notonlydoes ananatomicalrepairoftheBankartlesionhavetobeachieved, butalsoitisfundamentaltoidentifytheriskfactorsthathave beenprovedtobeassociatedwithfailureofarthroscopic treat-ment,suchasfailuretorecognizeaglenohumeralbonedefect or aredundant anteriorcapsule.3,14 Theopen techniqueis indicatedincasesofextensivebonelesions.
The aim of this study was to evaluate whether using anchors with double loading for treating traumatic ante-riorinstabilityoftheshoulderimprovestheclinicalresults, particularlywithregard torecurrence,andtocompare this techniquewiththeresultsfromusinganchorsloadedwitha singlethread.
Materials
and
methods
Thiswasaretrospectiveanalysisonpatientswhoweretreated at ourinstitution between 2000and 2010, for arthroscopic repair of a Bankart lesion. The inclusion criteria were: (1) recurrent traumaticanterior instability ofthe shoulder; (2) glenoidbonedefectsand/orHill–Sachslesion<25%;(3)signing oftheconsentstatementspecifiedbytheethicscommittees of the hospitalsinvolved. Patients withlarge humeral and glenoid bone defects, posterior instability, associated rota-tor cuff injuriesor previous surgeryon the shoulderwere excluded. Patients with associated SLAP lesions were not excluded.
Between December 2007 and August 2010, 59 consecu-tivepatients(61shoulders)underwentarthroscopictreatment of Bankart lesions using metal anchors with double load-ingofhigh-resistancethread(doublegroup).Thisgroupwas comparedwithasecondgroupformedby202patients(206 shoulders)whounderwentthesameprocedurebetween Jan-uary2000andNovember2005,butwithanchorsusingsingle loading(singlegroup).Thecharacteristicsofthetwogroups are compared inTable 1. The minimum follow-up was 24 months.
Table1–Comparativeepidemiologicalprofileofthe groupsthatunderwentBankartsurgery.
Characteristics Singlegroup
(n=206)
Doublegroup (n=52)
Meanageatfirstepisode 23.1±8.2 22.3±7.8
Meanageattimeofsurgery 33.4±10.6 27.6±7.9
Sex(male/female) 181/46 25/04
Dominantside 121(58.7%) 26(50%)
SLAPlesion 69(33.5%) 11(23.9%)
Meannumberofanchors 3.7 3.11
theaffectedshoulderwasmaintainedatabductionof30◦, flex-ionof15◦anddorsalinclinationofthetrunkof30◦.Weused classicalarthroscopicportals,withthearthroscopepositioned
in the anterosuperior portal, instruments applied through
theanteroinferiorportalandirrigationthroughtheposterior portal.Theglenohumeraljointwasinspectedandthe patho-logicalconditionwasverified(Fig.1).Debridementofthearea oftheBankartlesionwasthenperformed,withdecortication oftheanteriorborderoftheglenoidandtheadjacentscapular neck,usingamotorizedshaver.Wemarkedoutthepointsfor fixationofthe4mmmetalanchors(Revo,ConMed/Linvatec). Theanchorsinthedoublegroupwereloadedwithtwobraided nonabsorbablesuturethreads(Ethibondno.2).Theanchors neededtobepositionedataninclinationof45◦inrelationto thesurfaceoftheglenoidandforwardoftheglenoidborder medially,byupto3mm.Thefirstanchorintherightshoulder wasintroducedinthefiveo’clockpositionandthe remain-derwithminimumspacingof1cm,superiorly.Afterinsertion ofeachanchor,acurvedsoft-tissuepenetrator(suturehook) waspassedthroughwithano.1monofilamentthread,firstly throughthelabrum andthe anteriorbranchofthe inferior glenohumeralligament,atapointlocatedapproximately1cm caudally inrelationtoits respectiveanchor.Thefirst non-absorbablethreadwastiedtothemonofilamentthreadand transportedthroughthetissue.Thetissuewastensionedupon
Fig.1–Viewthroughtheanterosuperiorportalshowing Bankartlesionandanteriorbranchoftheinferior glenohumeralligament.
Fig.2–Retensioningoftheinferiorglenohumeralligament afterperformingthefirstsuture.
meetingtheanchorandfiveintercalatedknots(“Revo”type) weretiedforfixation(Fig.2).
Inthecaseofthepatientsinthedoublegroup,thesecond threadoftheanchorwaspassedthroughinthesamemanner, withtransfixationoftheremainderofthetissuethatwasstill slack(Figs.3and4).Thisreinforcementimprovedtheeffectof capsule-ligamentretensioning.Theotheranchorswerethen positioned,untilcompletingtherepairontheBankartlesion. Three anchorswere generally used,with sixanteroinferior labralrepairstitches(Fig.5).Whenpresent,SLAPlesionswere repairedinaccordancewiththetypepresented.
Thepatientswereimmobilizedwithfull-timeuseofa Vel-peau sling (neutral abduction and internalrotation of 70◦)
Fig.4–Appearanceoftheanteriorbranchoftheinferior glenohumeralligamentafterperformingthesecondsuture onthelowestanchor.
and were encouraged to perform flexion-extension of the elbowtwice a day. Three weeks later,the sling was with-drawnandthepatientstartedaphysiotherapyprogramaimed atachievingpassive gains inrangeofmotion,in all direc-tions.Musclestrengthening wasstarted12 weeksafterthe operation,andcompleteparticipationinsportsactivitieswas allowed6monthsaftertheoperation.
Theclinicalassessmentanddata-gatheringweredonebya physicianundergoingaspecializationprogram(R4)in shoul-der surgery, and these procedures consisted of a physical examinationandapplicationofaquestionnaire.Thepatients were askedabout theirfirst episodeofinstability, the type ofsports practiced and their return to the sport after the
Fig.5–Completedrepairontheanteriorcapsulolabral complexafterperformingsixsutures(threeanchorswith doublestitches).
Table2–Differenceinrecurrenceafterarthroscopic Bankartprocedure.
Group Totalnumberof
recurrences
Totalnumber ofpatients
Recurrence rate(%)
Double 4 52 7.69%a
Single 12 206 5.83%a
a p=0.62.
procedure. Their range of motion was measured using a goniometer and this was compared with the contralateral side.ThefunctionalscalesusedwereUCLAandCarter-Rowe. Recurrenceorsurgicalfailure wasdefinedasasituationin whichthepatientpresentedsomeevidenceorsymptomof instability(insecurity,subluxationordislocation).
Forthedescriptivestatisticalanalysesandthetests pre-sentedinthisstudy,weusedtheIBMSPSSstatisticalpackage, version19.0.0.Inordertotestwhetherthefrequenciesofthe two categoricalvariablespresentedany degreeof indepen-dence, we usedthe chi-square test. Themagnitudeof the associationbetweenpairsofcategoricalvariableswas mea-sured bymeansofSpearman’s correlation test.In orderto testandmeasurethedegreeofcorrelationoftheresponses betweentwovariablesofcontinuousnature,Pearson’s corre-lationtestwasused.Becauseoftheneedtocomparethedata obtainedinthetwostudies,weusedStudent’sttestto ascer-tainthesignificanceofthedifferencebetweenthemeansof thedifferentsamples.However,thettestwouldshowa dif-ferenceifthevarianceofthedatainthetwosampleswasthe sameordifferent.Therefore,insuchcases,thefirststepwas totestthenullhypothesisofequalitybetweenthevariances. Forthis,weusedFisher’sFtest.15
Results
Therewasnostatisticaldifferenceintheincidenceof recur-rencebetweenthegroupwithsingleloadingofanchors(5.83%) andthegroupwithdoubleloadingofanchors(7.69%),atthe endofthefollow-upperiod(Table2).
Attheendofthestudyperiod(afteraminimum follow-up of2years), the twogroupspresentedsimilar resultsin thegood-excellentrange,accordingtotheCarter-Rowe crite-ria,althoughadifferencearosewhenthemeanvalueofthe classificationwasevaluated(Table3).AccordingtotheUCLA functionalscale,therewasnodifferencebetweenthegroups: meanvalueforthesinglegroupof33.64andforthedouble group,34.25(p=0.178).PresenceofaSLAPlesiondidnot inter-ferewithpostoperativefunction.
Thepatientsinthedoublegrouppresentedameanlossof lateralrotationof13.93◦(p<0.001)withthearmadducted,in
Table3–Comparisonoffunctionalresultsaccordingto Carter-Rowe.
Result Singlegroup Doublegroup Significance
Poor/fair 8.3% 10.7% p=0.917
Good/excellent 91.7% 89.3% p=0.917
Table4–Returntosportsactivitiesafterrepairof Bankartlesion.
Singlegroup Doublegroup p
Samelevel 121(79.1%) 31(72.1%) 0.215
Lowerlevel 10(6.5%) 5(11.6%) 0.278
Didnotreturn 22(14.4%) 7(16.3%) 0.516
relationtothecontralateralshoulder.Withthearmadducted at90◦,thelosswas16.29◦(p<0.001).Therewasnodifference inrelationtoanteriorelevationormedialrotation.
Therewas atendency towardgreater return tosport at
thesamelevelasbeforethesurgeryinthesinglegroup,but withoutstatisticalsignificance(Table4).Forthisanalysis,53 patientsinthesinglegroupandseveninthedoublegroupwho weresedentarywereexcluded.
Discussion
Bothgroupsinthepresentstudyhadfailurerateslowerthan 10%,whichiscomparabletothesuccessratesinother stud-iesthatusedanchorswith2yearsoffollow-up.2,9,16–18 Kim etal.19 weretheonlyauthorstopublishaseriesofpatients withtraumaticanteriorinstabilitywhoweretreatedbymeans ofarthroscopicrepairusinganchorswithdoubleloadingof thread,andtheypresentedarecurrencerateof8.9%,which wasaresultverysimilar tothe 7.69%ofthepresent study. However,the successratewasno greaterthaninthe com-parisongroupofpatientstreatedusinganchorswithsingle loading.
Theresultsachievedinbothgroupsofthepresentstudy weresimilartothoseinliteratures,9,19–24whenevaluatedby meansoftheCarter-Roweclassification,withgoodand excel-lentresultsoftheorderof90%.Likewise,Kimetal.19obtained excellentfunctionalresults,withameanCarter-Rowescore of96.8.However,incomparingthe groupsofourstudy,we foundthatincreasingthenumberofsuturestitchesdidnot correlatewithimprovementoffunction,especiallyin evalu-atingthemeanCarter-Rowescore,inwhichtherewasaworse resultinthegroupwithdoubleloading.
Wefoundanimportantlimitationofrangeofmotionin comparingtheresultswiththecontralateralsideamongthe patientswhounderwent repairsusinganchorswithdouble loading,particularlywithregardtolateralrotationwith abduc-tion.Eventhoughlossoflateralrotationhasbeenfoundtobe practicallyuniversalinseriesthatusedanchorswithsingle loadingofthread,2,18 weobtainedaresultthat was signifi-cantlybetterthanthatofKim’ssample(lossof7◦ofexternal rotationwithabduction).19Thismaybecausedbygreater ten-sioningoftheanteriorcapsule.Despitethisfinding,therewas nocorrelationbetweenlossoflateralrotationandrecurrence orworsefunctionalscores.
Ithasbeenshownintheliteraturethattheresultsfrom arthroscopicrepairofBankartlesionsusinganchorswithone threaddeterioratewiththepassageoftime.Castagnaetal.20 found a recurrence rate of 23% with a mean follow-up of 10.9years.VanderLindeetal.21recordedarecurrencerate of35%with8–10yearsoffollow-up,whichwasalready20% after2years.Webelievethatwiththeuseofdoublyloaded
anchors,therecurrenceratesmayberevealedtobeloweras thefollow-upperiodincreases.Theoretically,thissuperiority hasalreadybeenshowninarecentbiomechanicalstudyby Kamathetal.,13inwhichtheuseoftwoanchorswith dou-ble loadingpresentedresistancetofailurethatwas greater thanorequaltotheuseofthreeanchorswithasinglethread. Longerfollow-upwillbringbetterconclusionsregardingthis hypothesis.
Oneofthelimitationsofourstudywas thediscrepancy between the sample sizesof the twogroups, even though theywerehomogenousinrelationtoepidemiological charac-teristics.Anotherissueisthatthestudywasnotprospective andrandomized,whichmayhavegeneratedbias. Nonethe-less,ourstudyisthefirstcomparativestudyonarthroscopic repairoftraumaticanteriorinstabilityusinganchorswith sin-gleanddoubleloadingofthread.Furtherstudiesarenecessary inordertoclarifyandimprovethetechniquefortreatingthis pathologicalcondition.
Conclusion
So far, treatment of traumatic anterior instability using anchorswithdoubleloadingofthreaddoesnotpresentany advantageintermsofrecurrenceorfunctionalimprovement, inrelationtoanchorswithsingleloading.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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1.KronerK,LindT,JensenJ.Theepidemiologyofshoulder
dislocations.ArchOrthopTraumaSurg.1989;108(5):288–90.
2.VoosJE,LivermoreRW,FeeleyBT,AltchekDW,WilliamsRJ,
WarrenRF,etal.Prospectiveevaluationofarthroscopic
Bankartrepairsforanteriorinstability.AmJSportsMed.
2010;38(2):302–7.
3.BoileauP,VillalbaM,HéryJY,BalgF,AhrensP,NeytonL.Risk
factorsforrecurrenceofshoulderinstabilityafter
arthroscopicBankartrepair.JBoneJointSurgAm.
2006;88(8):1755–63.
4.PorcelliniG,CampiF,PegreffiF,CastagnaA,PaladiniP.
Predisposingfactorsforrecurrentshoulderdislocationafter
arthroscopictreatment.JBoneJointSurgAm.
2009;91(11):2537–42.
5.RobinsonCM,HowesJ,MurdochH,WillE,GrahamC.
Functionaloutcomeandriskofrecurrentinstabilityafter
primarytraumaticanteriorshoulderdislocationinyoung
patients.JBoneJointSurgAm.2006;88(11):2326–36.
6.LaneJG,SachsRA,RiehlB.Arthroscopicstaple
capsulorrhaphy:along-termfollow-up.Arthroscopy.
1993;9(2):190–4.
7.GranaWA,BuckleyPD,YatesCK.ArthroscopicBankartsuture
repair.AmJSportsMed.1993;21(3):348–53.
8.GodinhoGG,SouzaJM,FreitasJMA,SantosFM,VieiraAW,
JoãoFM.Tratamentodainstabilidadeanteriordoombro
ExperiênciacomatécnicadeMorgan.RevBrasOrtop.
1997;32(4):265–71.
9.CarreiraDS,MazzoccaAD,OryhonJ,BrownFM,HaydenJK,
Bankartrepairs:minimum2-yearfollow-up.AmJSportsMed. 2006;34(5):771–7.
10.KimSH,HaKI,ChoYB,RyuBD,OhI.Arthroscopicanterior
stabilizationoftheshoulder:twotosix-yearfollow-up.JBone
JointSurgAm.2003;85(8):1511–8.
11.GodinhoGG,Franc¸aFO,FreitasJM,MenezesCM,FreireSG,
WanderleyAL,etal.Tratamentoartroscópicodainstabilidade
anteriortraumáticadoombro:resultadosemlongoprazoe
fatoresderisco.RevBrasOrtop.2008;43(5):
157–66.
12.WolfEM.Arthroscopiccapsulolabralrepairusingsuture
anchors.OrthopClinNorthAm.1993;24(1):59–69.
13.KamathGV,HooverS,CreightonRA,WeinholdP,BarrowA,
SpangJT.Biomechanicalanalysisofadouble-loadedglenoid
anchorconfiguration:canfeweranchorsprovideequivalent
fixation?AmJSportsMed.2013;41(1):163–8.
14.BurkhartSS,DeBeerJF.Traumaticglenohumeralbonedefects
andtheirrelationshiptofailureofarthroscopicBankart
repairs:significanceoftheinverted-pearglenoidandthe
humeralengagingHill–Sachslesion.Arthroscopy.
2000;16(7):677–94.
15.TriolaMF.Elementarystatistics:technologyupdate.11thed.
Boston:AddisonWesley;2010.
16.ThalR,NofzigerM,BridgesM,KimJJ.ArthroscopicBankart
repairusingknotlessorbioknotlesssutureanchors:2-to
7-yearresults.Arthroscopy.2007;23(4):367–75.
17.HantesME,VenouziouAI,LiantsisAK,DailianaZH,Malizos
KN.Arthroscopicrepairforchronicanteriorshoulder
instability:acomparativestudybetweenpatientswith
BankartlesionsandpatientswithcombinedBankartand
SLAP.AmJSportsMed.2009;37(6):1093–8.
18.NettoNA,TamaokiMJ,LenzaM,dosSantosJB,Matsumoto
MH,FaloppaF,etal.TreatmentofBankartlesionsin
traumaticanteriorinstabilityoftheshoulder:arandomized
controlledtrialcomparingarthroscopyandopentechniques.
Arthroscopy.2012;28(7):900–8.
19.KimKC,ShinHD,ChaSM,KimJH.Arthroscopic
double-loadedsingle-rowrepairinchronictraumaticanterior
shoulderdislocation.ArchOrthopTraumaSurg.
2012;132(10):1515–20.
20.CastagnaA,MarkopoulosN,ContiM,DelleRoseG,
PapadakouE,GarofaloR.ArthroscopicBankartsuture-anchor
repair:radiologicalandclinicaloutcomeatminimum10
yearsoffollow-up.AmJSportsMed.2010;38(10):2012–6.
21.VanderLindeJA,VanKampenDA,TerweeCB,DijksmanLM,
KleinjanG,WillemsWJ.Long-termresultsafterarthroscopic
shoulderstabilizationusingsutureanchors:an8-to10-year
follow-up.AmJSportsMed.2011;39(11):2396–403.
22.YanH,CuiGQ,WangJQ,TianDX,AoYF.ArthroscopicBankart
repairwithsutureanchors:resultsandriskfactorsof
recurrenceofinstability.ZhonghuaWaiKeZaZhi.
2011;49(7):597–602.
23.ZaffagniniS,MarcheggianiMuccioliGM,GiordanoG,
BonanzingaT,GrassiA,NitriM,etal.Long-termoutcomes
afterrepairofrecurrentpost-traumaticanteriorshoulder
instability:comparisonofarthroscopictransglenoidsuture
andopenBankartreconstruction.KneeSurgSports
TraumatolArthrosc.2012;20(5):816–21.
24.Mahiro ˘gullarıM,OzkanH,AkyüzM,U ˘gras¸AA,GüneyA,
Kus¸kucuM.Comparisonbetweentheresultsofopenand
arthroscopicrepairofisolatedtraumaticanteriorinstability
