Long-Term Restoration of Anterior Shoulder Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Procedure

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1 Zurich Open Repository an Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich Year: 2016 Long-Term Restoration of Anterior Shouler Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Proceure Zimmermann, Stefan; Scheyerer, Max; Farsha, Maza; Catanzaro, Sabrina; Rahm, Stefan; Gerber, Christian OI: Poste at the Zurich Open Repository an Archive, University of Zurich ZORA URL: Publishe Version Originally publishe at: Zimmermann, Stefan; Scheyerer, Max; Farsha, Maza; Catanzaro, Sabrina; Rahm, Stefan; Gerber, Christian (2016). Long-Term Restoration of Anterior Shouler Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Proceure. Journal Bone Joint Surgery America, 23: OI:

2 1954 COPYRIGHT Ó 2016 BY THE JOURNAL OF BONE AN JOINT SURGERY, INCORPORATE Long-Term Restoration of Anterior Shouler Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Proceure Stefan M. Zimmermann, M, Max J. Scheyerer, M, Maza Farsha, M, MPH, Sabrina Catanzaro, RN, Stefan Rahm, M, an Christian Gerber, M, FRCS Investigation performe at the Balgrist University Hospital, Zürich, Switzerlan Backgroun: Various operative techniques are use for treating recurrent anterior shouler instability, an goo mi-term results have been reporte. The purpose of this stuy was to compare shouler stability after treatment with the 2 commonly performe proceures, the arthroscopic Bankart soft-tissue repair an the open coracoi transfer accoring to Latarjet. Methos: A comparative, retrospective case-cohort analysis of 360 patients (364 shoulers) who ha primary repair for recurrent anterior shouler instability between 1998 an 2007 was performe. The minimum uration of follow-up was 6 years. Reoperations, overt recurrent instability (efine as recurrent islocation or subluxation), apprehension, the subjective shouler value (SSV), sports participation, an overall satisfaction were recore. Results: An open Latarjet proceure was performe in 93 shoulers, an an arthroscopic Bankart repair was one in 271 shoulers. Instability or apprehension persiste or recurre after 11% (10) of the 93 Latarjet proceures an after 41.7% (113) of the 271 arthroscopic Bankart proceures. Overt instability recurre after 3% of the Latarjet proceures an after 28.4% (77) of the Bankart proceures. In the Latarjet group, 3.2% of the patients were not satisfie with their result compare with 13.2% in the Bankart group (p = 0.007). Kaplan-Meier analysis of survivorship, with apprehension (p < 0.001), reislocation (p = 0.01), an operative revision (p < 0.001) as the en points, ocumente the substantial superiority of the Latarjet proceure an the ecreasing effectiveness of the arthroscopic Bankart repair over time. Twenty percent of the first recurrences after arthroscopic Bankart occurre no earlier than 91 months postoperatively, as oppose to the rare recurrences after osseous reconstruction, which occurre in the early postoperative perio, with only rare late failures. Conclusions: In this retrospective cohort stuy, the arthroscopic Bankart proceure was inferior to the open Latarjet proceure for repair of recurrent anterior shouler islocation. The ifference between the 2 proceures with respect to the quality of outcomes significantly increase with follow-up time. Level of Evience: Therapeutic Level III. See Instructions for Authors for a complete escription of levels of evience. Peer review: This article was reviewe by the Eitor-in-Chief an one eputy Eitor, an it unerwent bline review by two or more outsie experts. It was also reviewe by an expert in methoology an statistics. The eputy Eitor reviewe each revision of the article, an it unerwent a final review by the Eitor-in-Chief prior to publication. Final corrections an clarifications occurre uring one or more exchanges between the author(s) an copyeitors. Recurrent anterior shouler instability is a isabling conition that is commonly treate with either an arthroscopic Bankart repair 1,2 or an open Latarjet 3 proceure. After arthroscopic Bankart repairs, instability recurrence rates have been reporte to range from 0% to 37.5% 4,5, while recurrence rates after the open Latarjet proceure have been reporte to range from 1.7% to 14.2% 6-11, such that the latter is consiere to restore stability better than the arthroscopic Bankart repair 12. Most of these mi-term comparative stuies, however, were limite because of a lack of longer-term follow-up. The aim of the current stuy was to compare the recurrence rates an timing of recurrence after arthroscopic Bankart repair 13 an after the open Latarjet proceure 14. Our hypotheses were that the Latarjet proceure restores both shouler stability an function better than the arthroscopic Bankart repair an that the expecte ifference in restore stability increases over time. isclosure: The authors report no external funing source for this stuy. The isclosure of Potential Conflicts of Interest forms are provie with the online version of this article. J Bone Joint Surg Am. 2016;98:

3 1955 TABLE I Patient Characteristics an Follow-up Bankart Group (N = 271) Latarjet Group (N = 93) P Value Age at time of inex surgery* (yr) 28.2 ± ± Male patients (%) <0.001 ominant sie involve (%) uration of follow-up* (mo) 146 ± ± 23.2 <0.001 *The values are given as the mean an the stanar eviation. Materials an Methos With approval of the responsible ethical committee, a retrospective comparative case-cohort analysis was performe for all patients who ha unergone a primary arthroscopic Bankart repair or a primary open Latarjet proceure for recurrent anterior glenohumeral joint instability at our institution. A 10-year stuy perio was set from January 1, 1998, to ecember 31, 2007, ensuring a minimum follow-up of 6 years. Within the observation perio, 815 Bankart an Latarjet proceures were performe at our institution, an 504 of them were first-time proceures for shouler instability. The exclusion criteria were previous instability surgery, posterior or multiirectional instability, convulsive isorers, or concomitant, massive rotator cuff tears. Seventeen shoulers that met one of these criteria were exclue. Between 1998 an 2001, 70 shoulers with recurrent anterior instabilities associate with glenoi rim lesions were treate with an open proceure other than a Latarjet proceure. Another 12 open Bankart, reverse Bankart, segmental humeral hea reconstruction, or labral repair proceures for painful shoulers not associate with recurrent anterior islocations were exclue. Arthroscopic Bankart repairs were performe only on shoulers with no anterior glenoi rim lesions or on those with anterior glenoi rim lesions involving less than half of the length of the maximum glenoi iameter, which correspons to a loss of approximately 9% to 10% of the total glenoi surface 15,16. A total of 405 shoulers in 401 patients met the inclusion criteria. A Latarjet proceure was performe on 106 shoulers an an arthroscopic Bankart, on 299 shoulers. Of these, 13 patients (12%) in the Latarjet group an 28 patients (9.4%) in the Bankart group were lost to follow-up. Three of these patients were contacte, but they ecline to participate in the stuy; the others coul not be trace. Therefore, a total of 364 shoulers in 360 patients were inclue in the stuy, resulting in an overall follow-up rate of 89.9% (93 shoulers in the Latarjet group an 271 in the Bankart group). The mean age, sex istribution, ominant extremity involvement, an clinical follow-up time are summarize in Table I. The Latarjet proceure was performe accoring to the Walch refinement of the original technique escribe by Latarjet 3,14,17. Through a eltopectoral approach, the pectoralis minor tenon was release from the coracoi. The coracoacromial ligament was ivie 1 cm lateral to the coracoi. The coracoi was osteotomize at its base, an the posterior surface was cleane an flattene using an oscillating saw. Two anteroposterior 3.5-mm rill-holes, separate by at least 1.5 cm, were then rille through the coracoi. The subscapularis muscle was split longituinally slightly below its mi-level. Following a vertical capsule incision as close to the glenoi rim as possible, a humeral retractor was introuce into the joint. The anteroinferior aspect of the labrum was resecte, an the coracoi was positione flush with the glenoi plane on the anterior aspect of the scapular neck at the 2 to 5 o clock position in a right shouler (10 to 7 o clock in a left shouler) an was fixe with two 4.5-mm AO malleolar screws (Synthes). The stump of the coracoacromial ligament was suture to the most meial aspect of the joint capsule. The patients wore a sling for 10 ays an were allowe to return to sports at the en of the fourth month. For the arthroscopic Bankart repair, the patient was place in the lateral ecubitus position with the arm abucte approximately 45 with longituinal traction of 3 kg. The joint was examine through a posterior viewing portal. The anterior capsulolabral complex was free from the anterior aspect of the scapular neck to the 6 o clock position using a sharp, curve rasp until the subscapularis muscle was easily visible. For aequate exposure of the inferior part, the arm was often abucte to approximately 70. The anterior aspect of the scapular neck was cleane using a motorize burr. The inferior glenohumeral ligament was then reinserte using 3 (or 4) anchors positione at the ege between the glenoi surface an the scapular neck at the 5, 4, an 2 o clock positions. For the reinsertion, the capsule was shifte from inferior to superior, an for very inferior etachments, the most inferior stitch was performe through the posterior portal to gain more inferior access. Nonabsorbable number-2 sutures an nonabsorbable anchors were use. The patients wore a sling for 4 weeks, an participation in sports was not allowe for 6 months. Fig. 1 Fig. 2 Fig. 1 Kaplan-Meier survivorship analysis, with reislocation as the en point, for the Bankart an Latarjet groups over time, with the shae area inicating the 95% confience interval (p = 0.01). Fig. 2 Kaplan-Meier survivorship analysis, with surgical revision as the en point, for the Bankart an Latarjet groups over time, with the shae area inicating the 95% confience interval (p < 0.001).

4 1956 Fig. 3 Kaplan-Meier survivorship analysis, with recurrence or persistence of apprehension or overt instability as the en point, for the Bankart an Latarjet groups over time, with the shae area inicating the 95% confience interval (p < 0.001). The majority of the proceures were performe by the senior author (C.G.), with the remaining proceures performe by 2 fellowship-traine shouler surgeons experience in both techniques. The choice of the proceure was at the iscretion of the surgeon if there was no osseous lesion of the anterior glenoi rim that was longer than 50% of the maximum anteroposterior glenoi iameter measure on routinely performe preoperative compute tomography (CT) arthrograms 16. If the osseous lesion was >50%, a Latarjet proceure was performe, as it is known that larger glenoi rim lesions are associate with a high recurrence rate after arthroscopic Bankart proceures 18,19. Clinical outcome parameters, incluing evience of recurrent instability (anterior apprehension or recurrent overt instability [subluxation an reislocation]), revision for recurrent instability, the mean time to recurrence, incapacity for work, an sports participation, were recore. Anterior apprehension was efine as the subjective sensation of fear of the shouler islocating with the arm positione in abuction an external rotation. Subluxation was efine as the subjective sensation of glenohumeral slipping or shifting followe by either spontaneous reuction or manual resetting of the joint by the patient 20. Reislocation was efine as any ocumente islocation requiring reuction by a thir party or meical professional. All types of recurrences were recore separately, with the first time of occurrence of a type of instability as the first metric an the first time of recurrence as the secon key metric. If a patient ha a first-time recurrence of subluxation at 1 year an a reislocation at 2 years, he or she was liste as having subluxation an islocation; if a patient ha a recurrent islocation without subluxation or apprehension, he or she was liste as having reislocation only. The time to recurrence was recore until 80% an 95% of the first recurrences after the inex repair ha occurre. All patients were contacte, an the information for the stuy was obtaine from a etaile follow-up questionnaire that was complete an returne by 92 patients an from a telephone interview, which use the same questionnaire an was complete by 272 patients. Overall patient satisfaction was grae as excellent, goo, fair, an poor. In aition, preoperative an postoperative subjective shouler values (SSVs) were compare 21. Statistical analysis was performe using Prism 5.0 software (GraphPa) an SPSS (version 22.0; IBM). ata were teste for normal istribution with the Kolmogorov-Smirnov test before using the Stuent t test for parametric ata or the Mann-Whitney U test for nonparametric ata. The chi-square test was use to assess ifferences between categorical ata. The level of significance was set at a p value of <0.05. Results At a mean follow-up of slightly over 10 years, reislocation ha occurre in 13% (36) of the 271 shoulers with a Bankart repair an in 1% (1) of the 93 shoulers with a Latarjet repair (p = ). Subluxation ha occurre after 19% (51) of the Bankart repairs an after 2% (2) of the Latarjet repairs (p = ), an apprehension was reporte for 29% (78) of the 267 patients (271 shoulers) in the Bankart group an for 9% (8) of the 93 patients in the Latarjet group (p < 0.001). Any type of subjective instability (apprehension, subluxation, an/or islocation) was present (persistent or recurrent) in 41.7% (113) of all 271 shoulers in the Bankart repair group an in 11% (10) of all 93 shoulers in the Latarjet group (p = ). At the final follow-up, the cumulative revision rate for recurrent instability was 21% (57 shoulers) in the Bankart group an 1% (1 shouler) in the Latarjet group (p = ). The mean time to recurrence of instability is summarize in Table II. The time to recurrence was very ifferent for the 2 groups. After 2 years, 61% (22) of the 36 future first-time Fig. 4 Fig. 5 Fig. 4 Patient satisfaction percentage. Fig. 5 Percentage of patients who returne to sports (p = 0.045), ha a permanent incapacity for work (p = 0.098), an/or receive a isability pension (p = 0.205).

5 1957 Fig. 6 The mean preoperative SSV (an stanar eviation) was 63 ± for the Bankart group an ± for the Latarjet group; the ifference was significant (p < ). The top an bottom of the box represent the 25th an 75th percentiles, the horizontal line insie the box represents the meian, the whiskers are the 10th an 90th percentiles, an the circle represents an outlier. reislocations ha not yet occurre in the Bankart group. This rate ecline, an 5 years after the inex operation, 17% (6) of the 36 observe first-time reislocations ha not yet occurre. In the Latarjet group, there was only 1 reislocation at 29 months postoperatively (Fig. 1). It was reuce an no further treatment was neee. In the Bankart group, 20% (15) of Fig. 7 The mean postoperative SSV (an stanar eviation) was ± for the Bankart group an ± for the Latarjet group; the ifference was significant (p < ). The top an bottom of the box represent the 25th an 75th percentiles, the horizontal line insie the box represents the meian, the whiskers are the 10th an 90th percentiles, an the circles represent outliers. The asterisks inicate extreme outliers.

6 1958 TABLE II Time to Recurrence or Revision Time to Recurrence* (mo) Bankart Group (N = 271) Latarjet Group (N = 93) P Value Any instability 32.7 ± ± Subluxation 45 ± ± Reislocation 34.8 ± Revision 94.2 ± *The values are given as the mean an the stanar eviation. No stanar eviation was possible in the Latarjet group because only 1 patient ha reislocation an revision. the 77 ultimate first-time recurrences ha not yet occurre at 91 months postoperatively an 5% (4) ha not yet occurre at 119 months postoperatively. In the Latarjet group, all 3 recore recurrences ha occurre 2 years postoperatively. One operative revision for recurrent instability as well as 4 aitional revisions for other reasons than recurrent instability were necessary in the Latarjet group. One patient ha a postoperative hematoma that require evacuation, 1 patient esire harware removal, an 1 patient ha the screws replace because they were too long an irritate the infraspinatus. Finally, 1 patient require seconary shouler arthroscopy with repair of a SLAP (superior labral anterior-posterior) tear within the observation perio. Thereafter, all but 1 of these patients ha an uneventful postoperative course. In the arthroscopic Bankart group, revision surgery because of recurrent instability became necessary up to >15 years postoperatively. Of these revisions, one-thir ha not been performe at the time of the 5-year follow-up (Fig. 2). Two patients in the Bankart group unerwent revision surgery for reasons other than recurrent instability. One patient reporte shouler pain following a sports accient 6 months after the initial surgery. Raiographic workup reveale a isplace anchor, which was remove. In another patient, a iagnostic shouler arthroscopy an an acromioplasty were performe because of persistent pain 2 years after surgery. Fig. 8 The mean ifference in the preoperative an postoperative SSVs was ± for the Bankart group an ± for the Latarjet group; the ifference was significant (p < 0.001). The top an bottom of the box represent the 25th an 75th percentiles, the horizontal line insie the box represents the meian, the whiskers are the 10th an 90th percentiles, an the circles represent outliers.

7 1959 TABLE III Sex as a Risk Factor for Recurrence After an Arthroscopic Bankart Repair Male (N = 184) Female (N = 87) P Value Any instability 40% (73) 46% (40) Reoperation 21% (39) 21% (18) Reislocation 16% (29) 8% (7) In accorance with reislocation an revision rates, a similar pattern with ecreasing effectiveness of the Bankart repair over time was also ocumente for apprehension or overt instability (Fig. 3). The relationship between sex an recurrence rates coul not be analyze in the Latarjet group because of the small number of recurrences. In the Bankart group, reislocation occurre approximately twice as frequently in men as in women (p = 0.013) (Table III). There was, however, no significant ifferencebetweentherateofoperativerevisionsoroverallrecurrence of instability between men an women. The majority of all patients reporte at least a fair postoperative result. However, there was a significantly higher percentage of issatisfie patients in the Bankart group (13.2% versus 3.2%; p = 0.007). Furthermore, a higher percentage of highly satisfie patients was foun in the Latarjet group (77.4% versus 47.5%; p < ) (Fig. 4). Most patients were able to return to their previous sports activity, but the percentage of patients returning to their original sport was higher in the Latarjet group (p = 0.045) (Fig. 5). While the mean SSV improve significantly in both groups (p < 0.001), the mean postoperative SSV was slightly higher in the Latarjet group (89% versus 82%; p < ). As the mean preoperative SSV in the Latarjet group was significantly lower (p < ), the overall SSV improvement was significantly larger in the Latarjet group (p < 0.001) (Figs. 6, 7, an 8). Aitionally, the patients in the Latarjet group who i not report instability also ha a significantly higher mean SSV (91%) compare with the Bankart patients who were free of resiual instability (87%) (p = 0.002). The number of patients with a permanent incapacity for work or who were receiving workers compensation payments was negligible in both groups. iscussion In this retrospective stuy, the outcome of the open Latarjet proceure was substantially superior to that of the arthroscopic Bankart proceure in essentially all parameters stuie. It restore stability, patient satisfaction, an SSV significantly better than the arthroscopic Bankart proceure. There were few early an almost no late failures after the open Latarjet proceure, in contrast to the arthroscopic Bankart repair, which was associate with an increasing an substantial failure rate over time. Previous stuies have ocumente lower rates of recurrentinstabilityfollowingopenlatarjetproceuresthan after open 18,22 an arthroscopic Bankart (soft-tissue) repairs 12,23. To our knowlege, this stuy represents the largest comparative analysis of patient perception of the 2 most common proceures currently use for anterior shouler instability with a minimum follow-up perio of 6 years. We foun a subjectively an/or objectively imperfect restoration of stability after 41.7% (113) of the 271 arthroscopic Bankart repairs an after 11% (10) of the93openlatarjetproceures,whichishigherthanin the existing literature 12,22,23. This may be the result of longer follow-up, as many other stuies likely unerestimate recurrent instability because of the stanar minimum follow-up of 2 years, which seems inaequate for this pathology. At the 2-year follow-up in our stuy, the reislocation rates were 5.1% for the Bankart group an 0% for the Latarjet group. The revision rate at the 2-year follow-up was 9.6% for the Bankart an 1% for the Latarjet repairs. In agreement with the finings of Bessière et al. 23, more than half of the recurrent instabilities (61%) in our stuy occurre later than 2 years postoperatively an continue to occur progressively at lower rates thereafter. The contention that arthroscopic Bankart reconstructions fail progressively 5,12,24 is therefore confirme by our stuy, an the observation that restoration of stability with the Latarjet proceure is stable over time is supporte 6,8,22. The higher rate of recurrent instability in our stuy might also be the result of the efinition of recurrent instability. Previous stuies often efine recurrent instability as reislocation alone or as reislocation an subluxation. When consiering only reislocation an subluxation, we foun an overall recurrence rate of 3% for the Latarjet group an 28.4% for the Bankart group. For reislocation alone, the recurrence rates were 1% an 13%, respectively, which are largely comparable with other stuies in the literature. For etaile interpretation of the restore stability, apprehension was assesse as precisely as possible. Apprehension alone may lea to substantial restriction of everyay life as well as negatively affect overall outcome an specifically sports performance. This was confirme as 7 (1 in the Latarjet group an 6 in the Bankart group) of the 58 surgical revisions were performe for persistent apprehension without recurrent subluxation or reislocation. The transition from apprehension to subluxation may not always be perfectly clear. With the efinitions outline in the Materials an Methos section, patients appeare to be able to etermine to which group they belonge or to etermine that one form of instability ha evelope after the other. The preoperative SSV was lower for the Latarjet patients, suggesting that the preoperative isability was greater in the Latarjet group than in the Bankart group. At the time of final follow-up, however, the mean SSV was significantly higher in the Latarjet group (89% versus 82%; p < ). Therefore, the subjective benefit of shouler stabilization was significantly greater for the patients in the Latarjet group. We ha expecte that the more anatomical Bankart proceure woul lea to higher subjective satisfaction in the subgroup of patients who i not have recurrent instability. Instea, we foun that the

8 1960 Latarjet subgroup with no such instability symptoms fare significantly better (p = 0.002). There are limitations to this stuy. First an foremost, this investigation was neither a ranomize trial nor a controlle cohort stuy an therefore has an acknowlege selection bias. Shoulers with relevant glenoi rim lesions, involving >10% of the glenoi surface, are at high risk for recurrence after an arthroscopic Bankart repair 18,19. Those shoulers, therefore, were not consiere for arthroscopic Bankart repair. This le to a proportionally smaller group of patients without rim lesions in the Latarjet group. There is no suggestion in the literature that patients who have recurrent islocation with an intact anterior glenoi rim are poor caniates for the Latarjet proceure. The possibility that the absence of glenoi rim lesions eselects less well-suite patients with recurrent islocation for a Latarjet operation cannot be exclue; however, neither the results seen in our patients nor those in the literature support this hypothesis. Therefore, we assume that the patients in the Latarjet group were at greater risk for recurrence 19,25-27.Forclinicalpractice,webelieve that it woul be unethical to subject the patients with anterior glenoi rim lesions, who are known to have a high risk of recurrence after an arthroscopic Bankart repair an a better prognosis with a Latarjet proceure 19, to a ranomize trial. It appeare justifie, however, to compare patients who were consiere to be goo caniates for an arthroscopic Bankart with patients treate with a Latarjet proceure. The results of this stuy, however, ocument a clear superiority of the Latarjet proceure, even when excluing the majority of the poor-risk patients from the Bankart group. Furthermore, the stuy may be criticize because it was base on patient-reporte outcome only. Although aitional physical examination might have been interesting, the results of the interviews an questionnaires were foun to be appropriate for answering the stuy questions. Because of the lack of consistent raiographic follow-up, we were not able to evaluate the evelopment or progression of osteoarthritis. Other longterm stuies, however, have not shown an increase rate of arthritic changes following Latarjet proceures compare with soft-tissue reconstructions 22,24,28. The SSV, which is known to be influence by pain, was higher in the Latarjet group than in the Bankart group at the time of final follow-up. Thus, although a ifference in the evelopment of asymptomatic osteoarthritis was not formally exclue, we think that it is an unlikely element to influence the interpretation of our ata. Last, the follow-up rate of 90% is possibly less than esire, but is satisfactory with a minimum follow-up of 6 years an a maximum follow-up of 16 years. This follow-up rate compares favorably with stuies involving young, mobile patients with similar follow-up perios 23. In conclusion, the arthroscopic Bankart repair for the treatment of recurrent anterior glenohumeral joint instability is inferior to an open Latarjet proceure in our hans. It oes not restore stability, patient satisfaction, or the SSV to the same level as that after an open Latarjet proceure. Failures following the osseous reconstruction proceure are rare an typically occur early in the postoperative course. The effectiveness of an arthroscopic Bankart repair ecreases over the postoperative course an leas to a substantial number of late failures, with approximately 1 out of 5 first-time recurrences of instability occurring no earlier than 5 years postoperatively. Therefore, we o not recommen an arthroscopic Bankart proceure to our patients who have recurrent anterior islocation. n Stefan M. Zimmermann, M 1 Max J. Scheyerer, M 1 Maza Farsha, M, MPH 1 Sabrina Catanzaro, RN 1 Stefan Rahm, M 1 Christian Gerber, M, FRCS 1 1 Balgrist University Hospital, Zürich, Switzerlan aress for C. Gerber: christian.gerber@balgrist.ch References 1. Cole BJ, Romeo AA. Arthroscopic shouler stabilization with suture anchors: technique, technology, an pitfalls. Clin Orthop Relat Res Sep;390: Wolf EM. Arthroscopic capsulolabral repair using suture anchors. Orthop Clin North Am Jan;24(1): Latarjet M. [Treatment of recurrent islocation of the shouler]. Lyon Chir Nov-ec;49(8): French. 4. Hobby J, Griffin, unbar M, Boileau P. Is arthroscopic surgery for stabilisation of chronic shouler instability as effective as open surgery? A systematic review an meta-analysis of 62 stuies incluing 3044 arthroscopic operations. 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