Clinical trial NCT02535585: Arthroscopic Treatment of Anterior Shoulder Dislocation Using Knotted and Knotless Anchors
Official title: Arthroscopic Treatment of Anterior Shoulder Dislocation Using Knotted and Knotless Anchors
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Shoulder Dislocation
Lead sponsor: University of Sao Paulo
Sponsor class: OTHER
First posted: 2015-08-28
Enrollment: 58
Sex: ALL
Standard ages: CHILD
ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: TREATMENT

Brief summary: The shoulder is the joint that most commonly suffers dislocation, and anterior instability is the most frequent form. Arthroscopic repair is the gold standard for the treatment of recurrent shoulder dislocation. The most commonly used technique is the attachment of glenoid labrum-ligament complex (GLLC) with knotted anchors. In 2001, Thal introduced the concept of tissue fixation using knotless anchors and its applicability for GLLC lesions. Some researchers have published studies using knotless anchors and have compared this technique to the use of knotted anchors, demonstrating similar reconstruction of labral height and functional outcomes, while the recurrence rate is still contradictory. To date, there are no prospective randomized controlled clinical trial comparing these two techniques of GLLC repairs.

The researchers aims to compare clinical outcomes and imaging evaluation of patients undergoing GLLC repair arthroscopically with the use of absorbable knotless and knotted anchors.

Detailed description: The shoulder is the joint that most commonly suffers dislocation, and anterior instability is the most frequent form. The overall incidence of first-time dislocations requiring closed reduction is 23.1 per 100,000 people/year, with a higher incidence in males and Caucasians. Individuals with a younger age at first dislocation show a higher rate of recurrence.

Arthroscopic repair is the gold standard for the treatment of recurrent shoulder dislocation, with similar outcomes to open repair. The technique is less aggressive because the tendon of the subscapularis does not need to be addressed, leading to shorter hospital stays, less scarring, earlier return to normal activities, and a greater postoperative range of motion.

In this technique, the glenoid labrum-ligament complex (GLLC) is repaired using bone anchors that can be metallic, absorbable, or flexible. Biomechanical studies have shown that these three types of anchors are similar in terms of cyclic loading resistance and bone fixation. Absorbable anchors are most frequently used because metallic anchors can cause postoperative imaging interference in MRI study, can migrate and became loose or break, which can damage the articular cartilage. Flexible anchors when submitted to cyclic stress can produce cystic cavities in bone tissue attachment 21, and probably can lead to a failure of glenoid labrum-ligament complex suture.

The most commonly used technique is the attachment of GLLC with knotted anchors. Studies have shown to perform an arthroscopic knot is challenging and can be technically difficult. The knot volume can produce friction during the shoulder movement, leading joint discomfort and cartilage damage. The quality of the soft tissue healing depend on the knot quality too. The dislocation recurrence rate with this technique ranges from 4% to 19%.

In 2001, Thal introduced the concept of tissue fixation using knotless anchors and its applicability for GLLC lesions. Although this new technique had solved the difficulty of tying knots, the results regarding the GLLC suture shown more gap formation between this complex and the glenoid bone, delayed anchor loosening and postoperative arthropathy. The recurrence rate is high associated with perianchor radiolucency.The recurrence rate with this technique is as high as 23.8%.

Some researchers have published studies using knotless anchors and have compared this technique to the use of knotted anchors, demonstrating similar reconstruction of labral height and functional outcomes, while the recurrence rate is still contradictory. To date, there are no prospective randomized controlled clinical trial comparing these two techniques of GLLC repairs.

Our researchers aims to compare clinical outcomes and imaging evaluation of patients undergoing GLLC repair arthroscopically with the use of absorbable knotless and knotted anchors.

Eligibility criteria: Inclusion Criteria:

* Skeletal maturity;
* Anterior glenohumeral instability;
* Previous labral lesion without bone defects or with defects that affect no more than 20% of the anteroposterior diameter of the glenoid, as shown by MRI;
* Instability severity index score (ISIS) \< 4;

Non-Inclusion Criteria

* Epilepsy;
* Associated rotator cuff tear;
* Proximal humeral fracture;
* Multidirectional or posterior instability by clinical evaluation;
* Generalized ligamentous laxity by clinical evaluation;

Exclusion Criteria:

* Irreparable injury to the anterior capsule or injury to the humeral insertion of the inferior glenohumeral ligament;
* Glenoid bone defect greater than 20% of the anteroposterior diameter measured by arthroscopy;
* Rotator cuff tear found on arthroscopy;
* Abandonment of the rehabilitation program and follow-up before the first evaluation of outcomes

Primary outcomes:
measure: Rowe scale
timeFrame: 1 year
Secondary outcomes:
measure: dislocation recurrence rate
timeFrame: 1 year
measure: intraoperative and postoperative complications
timeFrame: 1 year
measure: WOSI
timeFrame: 1 year
measure: ASES
timeFrame: 1 year
measure: Magnetic resonance imaging - LGHI
timeFrame: 1 year
measure: Magnetic resonance imaging - Labral Slope
timeFrame: 1 year
measure: Magnetic resonance imaging - Labral morphology
timeFrame: 1 year
measure: Magnetic resonance imaging - Anchor resorption
timeFrame: 1 year
measure: Magnetic resonance imaging - Bone reaction
timeFrame: 1 year
Other outcomes:
Locations:
city: São Paulo
country: Brazil
facility: Departamento de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
state: SP
Study officials:
References:
citation: Cutts S, Prempeh M, Drew S. Anterior shoulder dislocation. Ann R Coll Surg Engl. 2009 Jan;91(1):2-7. doi: 10.1308/003588409X359123.
citation: Leroux T, Wasserstein D, Veillette C, Khoshbin A, Henry P, Chahal J, Austin P, Mahomed N, Ogilvie-Harris D. Epidemiology of primary anterior shoulder dislocation requiring closed reduction in Ontario, Canada. Am J Sports Med. 2014 Feb;42(2):442-50. doi: 10.1177/0363546513510391. Epub 2013 Nov 25.
citation: Owens BD, Dawson L, Burks R, Cameron KL. Incidence of shoulder dislocation in the United States military: demographic considerations from a high-risk population. J Bone Joint Surg Am. 2009 Apr;91(4):791-6. doi: 10.2106/JBJS.H.00514.
citation: Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM, Cole BJ, Bach BR Jr, Romeo AA, Verma NN. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy. 2013 May;29(5):920-33. doi: 10.1016/j.arthro.2012.11.010. Epub 2013 Feb 5.
citation: Bollier MJ, Arciero R. Management of glenoid and humeral bone loss. Sports Med Arthrosc Rev. 2010 Sep;18(3):140-8. doi: 10.1097/JSA.0b013e3181e88ef9.
citation: 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 Aug;85(8):1511-8.
citation: Carreira DS, Mazzocca AD, Oryhon J, Brown FM, Hayden JK, Romeo AA. A prospective outcome evaluation of arthroscopic Bankart repairs: minimum 2-year follow-up. Am J Sports Med. 2006 May;34(5):771-7. doi: 10.1177/0363546505283259.
citation: Burkhart SS, De Beer JF. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted-pear glenoid and the humeral engaging Hill-Sachs lesion. Arthroscopy. 2000 Oct;16(7):677-94. doi: 10.1053/jars.2000.17715.
citation: Fabbriciani C, Milano G, Demontis A, Fadda S, Ziranu F, Mulas PD. Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy. 2004 May;20(5):456-62. doi: 10.1016/j.arthro.2004.03.001.
citation: Hayashida K, Yoneda M, Mizuno N, Fukushima S, Nakagawa S. Arthroscopic Bankart repair with knotless suture anchor for traumatic anterior shoulder instability: results of short-term follow-up. Arthroscopy. 2006 Jun;22(6):620-6. doi: 10.1016/j.arthro.2006.03.006.
citation: Ng C, Bialocerkowski A, Hinman R. Effectiveness of arthroscopic versus open surgical stabilisation for the management of traumatic anterior glenohumeral instability. Int J Evid Based Healthc. 2007 Jun;5(2):182-207. doi: 10.1111/j.1479-6988.2007.00064.x.
citation: Kim SH, Ha KI, Kim SH. Bankart repair in traumatic anterior shoulder instability: open versus arthroscopic technique. Arthroscopy. 2002 Sep;18(7):755-63. doi: 10.1053/jars.2002.31701.
citation: Hobby J, Griffin D, Dunbar M, Boileau P. Is arthroscopic surgery for stabilisation of chronic shoulder instability as effective as open surgery? A systematic review and meta-analysis of 62 studies including 3044 arthroscopic operations. J Bone Joint Surg Br. 2007 Sep;89(9):1188-96. doi: 10.1302/0301-620X.89B9.18467.
citation: Cooke SJ, Starks I, Kathuria V. The results of arthroscopic anterior stabilisation of the shoulder using the bioknotless anchor system. Sports Med Arthrosc Rehabil Ther Technol. 2009 Jan 19;1(1):2. doi: 10.1186/1758-2555-1-2.
citation: Barber FA, Herbert MA. Cyclic loading biomechanical analysis of the pullout strengths of rotator cuff and glenoid anchors: 2013 update. Arthroscopy. 2013 May;29(5):832-44. doi: 10.1016/j.arthro.2013.01.028. Epub 2013 Apr 2.
citation: Mazzocca AD, Chowaniec D, Cote MP, Fierra J, Apostolakos J, Nowak M, Arciero RA, Beitzel K. Biomechanical evaluation of classic solid and novel all-soft suture anchors for glenoid labral repair. Arthroscopy. 2012 May;28(5):642-8. doi: 10.1016/j.arthro.2011.10.024. Epub 2012 Feb 1.
citation: Gaenslen ES, Satterlee CC, Hinson GW. Magnetic resonance imaging for evaluation of failed repairs of the rotator cuff. Relationship to operative findings. J Bone Joint Surg Am. 1996 Sep;78(9):1391-6. doi: 10.2106/00004623-199609000-00015.
citation: Silver MD, Daigneault JP. Symptomatic interarticular migration of glenoid suture anchors. Arthroscopy. 2000 Jan-Feb;16(1):102-5. doi: 10.1016/s0749-8063(00)90136-1.
citation: Rhee YG, Lee DH, Chun IH, Bae SC. Glenohumeral arthropathy after arthroscopic anterior shoulder stabilization. Arthroscopy. 2004 Apr;20(4):402-6. doi: 10.1016/j.arthro.2004.01.027.
citation: Kaar TK, Schenck RC Jr, Wirth MA, Rockwood CA Jr. Complications of metallic suture anchors in shoulder surgery: A report of 8 cases. Arthroscopy. 2001 Jan;17(1):31-7. doi: 10.1053/jars.2001.18246.
citation: Pfeiffer FM, Smith MJ, Cook JL, Kuroki K. The histologic and biomechanical response of two commercially available small glenoid anchors for use in labral repairs. J Shoulder Elbow Surg. 2014 Aug;23(8):1156-61. doi: 10.1016/j.jse.2013.12.036. Epub 2014 Apr 13.
citation: Rhee YG, Ha JH, Cho NS. Anterior shoulder stabilization in collision athletes: arthroscopic versus open Bankart repair. Am J Sports Med. 2006 Jun;34(6):979-85. doi: 10.1177/0363546505283267. Epub 2006 Jan 25.
citation: Mazzocca AD, Brown FM Jr, Carreira DS, Hayden J, Romeo AA. Arthroscopic anterior shoulder stabilization of collision and contact athletes. Am J Sports Med. 2005 Jan;33(1):52-60. doi: 10.1177/0363546504268037.
citation: Ide J, Maeda S, Takagi K. Arthroscopic Bankart repair using suture anchors in athletes: patient selection and postoperative sports activity. Am J Sports Med. 2004 Dec;32(8):1899-905. doi: 10.1177/0363546504265264.
citation: Cho NS, Hwang JC, Rhee YG. Arthroscopic stabilization in anterior shoulder instability: collision athletes versus noncollision athletes. Arthroscopy. 2006 Sep;22(9):947-53. doi: 10.1016/j.arthro.2006.05.015.
citation: Thal R. Knotless suture anchor: arthroscopic bankart repair without tying knots. Clin Orthop Relat Res. 2001 Sep;(390):42-51.
citation: Riboh JC, Heckman DS, Glisson RR, Moorman CT 3rd. Shortcuts in arthroscopic knot tying: do they affect knot and loop security? Am J Sports Med. 2012 Jul;40(7):1572-7. doi: 10.1177/0363546512446676. Epub 2012 May 10.
citation: Loutzenheiser TD, Harryman DT 2nd, Yung SW, France MP, Sidles JA. Optimizing arthroscopic knots. Arthroscopy. 1995 Apr;11(2):199-206. doi: 10.1016/0749-8063(95)90067-5.
citation: Thal R, Nofziger M, Bridges M, Kim JJ. Arthroscopic Bankart repair using Knotless or BioKnotless suture anchors: 2- to 7-year results. Arthroscopy. 2007 Apr;23(4):367-75. doi: 10.1016/j.arthro.2006.11.024.
citation: Sugaya H, Moriishi J, Kanisawa I, Tsuchiya A. Arthroscopic osseous Bankart repair for chronic recurrent traumatic anterior glenohumeral instability. J Bone Joint Surg Am. 2005 Aug;87(8):1752-60. doi: 10.2106/JBJS.D.02204.
citation: Voos JE, Livermore RW, Feeley BT, Altchek DW, Williams RJ, Warren RF, Cordasco FA, Allen AA; HSS Sports Medicine Service. Prospective evaluation of arthroscopic bankart repairs for anterior instability. Am J Sports Med. 2010 Feb;38(2):302-7. doi: 10.1177/0363546509348049. Epub 2009 Dec 22.
citation: Thal R. A knotless suture anchor. Design, function, and biomechanical testing. Am J Sports Med. 2001 Sep-Oct;29(5):646-9. doi: 10.1177/03635465010290051901.
citation: Thal R. A Knotless Suture Anchor: Technique for use in arthroscopic Bankart repair. Arthroscopy. 2001 Feb;17(2):213-8. doi: 10.1053/jars.2001.20666.
citation: Zumstein M, Jacob HA, Schneeberger AG. In vitro comparison of standard and Knotless metal suture anchors. Arthroscopy. 2004 May;20(5):517-20. doi: 10.1016/j.arthro.2004.03.007.
citation: Antonogiannakis E, Yiannakopoulos CK, Karliaftis K, Karabalis C. Late disengagement of a knotless anchor. Arthroscopy. 2002 Oct;18(8):E40. doi: 10.1053/jars.2002.30008.
citation: Park JY, Lhee SH, Park HK, Jeon SH, Oh JH. Perianchor radiolucency after knotless anchor repair for shoulder instability: correlation with clinical results of 69 cases. Am J Sports Med. 2009 Feb;37(2):360-70. doi: 10.1177/0363546508324312. Epub 2008 Oct 20.
citation: Cho NS, Lubis AM, Ha JH, Rhee YG. Clinical results of arthroscopic bankart repair with knot-tying and knotless suture anchors. Arthroscopy. 2006 Dec;22(12):1276-82. doi: 10.1016/j.arthro.2006.07.005.
citation: Garofalo R, Mocci A, Moretti B, Callari E, Di Giacomo G, Theumann N, Cikes A, Mouhsine E. Arthroscopic treatment of anterior shoulder instability using knotless suture anchors. Arthroscopy. 2005 Nov;21(11):1283-9. doi: 10.1016/j.arthro.2005.08.033.
citation: Kocaoglu B, Guven O, Nalbantoglu U, Aydin N, Haklar U. No difference between knotless sutures and suture anchors in arthroscopic repair of Bankart lesions in collision athletes. Knee Surg Sports Traumatol Arthrosc. 2009 Jul;17(7):844-9. doi: 10.1007/s00167-009-0811-3. Epub 2009 Apr 29.
citation: Ng DZ, Kumar VP. Arthroscopic Bankart repair using knot-tying versus knotless suture anchors: is there a difference? Arthroscopy. 2014 Apr;30(4):422-7. doi: 10.1016/j.arthro.2014.01.005.
citation: Slabaugh MA, Friel NA, Wang VM, Cole BJ. Restoring the labral height for treatment of Bankart lesions: a comparison of suture anchor constructs. Arthroscopy. 2010 May;26(5):587-91. doi: 10.1016/j.arthro.2009.09.010. Epub 2010 Mar 4.
citation: Rowe CR, Patel D, Southmayd WW. The Bankart procedure: a long-term end-result study. J Bone Joint Surg Am. 1978 Jan;60(1):1-16.
citation: Piasecki DP, Verma NN, Romeo AA, Levine WN, Bach BR Jr, Provencher MT. Glenoid bone deficiency in recurrent anterior shoulder instability: diagnosis and management. J Am Acad Orthop Surg. 2009 Aug;17(8):482-93. doi: 10.5435/00124635-200908000-00002.
citation: Cho SH, Cho NS, Rhee YG. Preoperative analysis of the Hill-Sachs lesion in anterior shoulder instability: how to predict engagement of the lesion. Am J Sports Med. 2011 Nov;39(11):2389-95. doi: 10.1177/0363546511398644. Epub 2011 Mar 11.
citation: Saito H, Itoi E, Minagawa H, Yamamoto N, Tuoheti Y, Seki N. Location of the Hill-Sachs lesion in shoulders with recurrent anterior dislocation. Arch Orthop Trauma Surg. 2009 Oct;129(10):1327-34. doi: 10.1007/s00402-009-0854-4. Epub 2009 Mar 20.
citation: Burkhart SS, Debeer JF, Tehrany AM, Parten PM. Quantifying glenoid bone loss arthroscopically in shoulder instability. Arthroscopy. 2002 May-Jun;18(5):488-91. doi: 10.1053/jars.2002.32212.
citation: Lo IK, Parten PM, Burkhart SS. The inverted pear glenoid: an indicator of significant glenoid bone loss. Arthroscopy. 2004 Feb;20(2):169-74. doi: 10.1016/j.arthro.2003.11.036.
citation: Wolf EM. Anterior portals in shoulder arthroscopy. Arthroscopy. 1989;5(3):201-8. doi: 10.1016/0749-8063(89)90172-2.
citation: Dahl KA, Patton DJ, Dai Q, Wongworawat MD. Biomechanical characteristics of 9 arthroscopic knots. Arthroscopy. 2010 Jun;26(6):813-8. doi: 10.1016/j.arthro.2009.10.011.
citation: Stein T, Mehling AP, Reck C, Buckup J, Efe T, Hoffmann R, Jager A, Welsch F. MRI assessment of the structural labrum integrity after Bankart repair using knotless bio-anchors. Knee Surg Sports Traumatol Arthrosc. 2011 Oct;19(10):1771-9. doi: 10.1007/s00167-011-1407-2. Epub 2011 Feb 11.
citation: Hoffmann R, Weller A, Helling HJ, Krettek C, Rehm KE. [Local foreign body reactions to biodegradable implants. A classification]. Unfallchirurg. 1997 Aug;100(8):658-66. doi: 10.1007/s001130050172. German.
citation: Balg F, Boileau P. The instability severity index score. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilisation. J Bone Joint Surg Br. 2007 Nov;89(11):1470-7. doi: 10.1302/0301-620X.89B11.18962.
citation: Kirkley A, Griffin S, McLintock H, Ng L. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability. The Western Ontario Shoulder Instability Index (WOSI). Am J Sports Med. 1998 Nov-Dec;26(6):764-72. doi: 10.1177/03635465980260060501.
citation: Michener LA, McClure PW, Sennett BJ. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, patient self-report section: reliability, validity, and responsiveness. J Shoulder Elbow Surg. 2002 Nov-Dec;11(6):587-94. doi: 10.1067/mse.2002.127096.