The Open Orthopaedics Journal


ISSN: 1874-3250 ― Volume 11, 2017

The “Purse-string” Technique for Shoulder Stabilization, Description of the Technique, Long term Results and Literature Review



Georgios Arealis1, *, Joana Bento Rodrigues1, Natalie Hope2, Ofer Levy2
1 Reading Shoulder Unit, Royal Berkshire and Berkshire Independent Hospitals, Swallows Croft, Wensley Road, Coley Park, Reading, RG1 6UZ, United Kingdom
2 Reading Shoulder Unit, Royal Berkshire and Berkshire Independent Hospitals, Reading, UK

Abstract

Background:

Over the last 2 decades arthroscopic stabilization and Bankart repair has gained popularity due to the advances in materials and surgical techniques. Results of arthroscopic stabilization have been similar to open without the risks of it. The number of anchors used has been suggested to be very important in “spot-weld” arthroscopic stabilization however the “purse-string” technique (PST) can achieve similar results using only one anchor.

We describe technique and long term results from using the PST and search the literature for other papers regarding PST.

Methods:

Between 2003 and 2013 a total of 193 patients were operated. Patients included those with anterior instability. Using PubMed relevant studies reporting results of PST were identified.

Results:

Mean follow up was 2 (range 0.5 to 3) years. 9 (4.7%) patients experienced recurrent instability. Almost all patients (97%) returned to their sporting and leisure activities and all professional athletes went back to the same sport. One more UK centre reported 6.1% recurrence in 114 patients at 4 years follow up. These results are similar to the published 11% recurrence of instability after “spot-weld” arthroscopic techniques at 11 years clinical follow-up.

Conclusion:

This study indicates that PST is safe and effective alternative method for the treatment of anterior shoulder instability. In this technique with one anchor simultaneous repair of labrum, creation of an anterior bumper and capsular shift can be achieved. It has the advantage of being cheaper, faster yet efficient with good long term results and leaves space for revision anchors in case of recurrence.

Keywords: “purse-string” technique, Arthroscopic stabilization, Bankart, Number of anchors, Repair of labrum, Anterior shoulder instability, One anchor.


Article Information


Identifiers and Pagination:

Year: 2017
Volume: 11
Issue: Suppl-1, M11
First Page: 183
Last Page: 188
Publisher Id: TOORTHJ-11-183
DOI: 10.2174/1874325001711010183

Article History:

Received Date: 06/01/2016
Revision Received Date: 14/04/2016
Acceptance Date: 20/04/2016
Electronic publication date: 28/02/2017
Collection year: 2017

© 2017 Arealis et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at Reading Shoulder Unit, Royal Berkshire and Berkshire Independent Hospitals, Swallows Croft, Wensley Road, Coley Park, Reading, RG1 6UZ, United Kingdom, Fax: 0044 118 902 8138; Tel: 0044 785 637 1050; E-mail: garealis@yahoo.gr




INTRODUCTION

Repair of avulsion of the anterior inferior labrum from the glenoid rim that was first described in 1920 by Bankart [1Bankart AS. Recurrent or Habitual Dislocation of the Shoulder-Joint. BMJ 1923; 2(3285): 1132-3.
[http://dx.doi.org/10.1136/bmj.2.3285.1132] [PMID: 20771383]
] and earlier by Perthes [2Perthes G. Über Operationen bei habitueller Schulterluxation. Dtsch Z Chir 1906; 56: 149-51.] can be either open or arthroscopic. Over the recent years arthroscopic repair has increasingly popular and results have been very promising especially regarding post-operative stiffness and pain compared to open repair [3Fabbriciani 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 : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2004 [May;20];5: 456-62. Epub 2004/05/04. eng.
[PMID: 15122134] [http://dx.doi.org/10.1016/j.arthro.2004.03.001]
]. Patients also tend to prefer arthroscopic over open surgery [4Sperling JW, Smith AM, Cofield RH, Barnes S. Patient perceptions of open and arthroscopic shoulder surgery. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 20074 [ Apr 23];: 361-6. Epub 2007/04/10. eng.
[PMID: 17418327] [http://dx.doi.org/10.1016/j.arthro.2006.12.006]
].

Traditionally arthroscopic repair is performed using multiple suture anchors and a minimum of 3 anchors is perceived to be necessary to achieve optimum results restoring the labral “bumper”. [5Armangil M, Basat HC, Akan B, Karaduman M, Demirtaş M. Arthroscopic stabilization of anterior shoulder instability using a single anterior portal. Acta Orthop Traumatol Turc 2015; 49(1): 6-12. [eng.].
[PMID: 25803246]
, 6Cole BJ, Romeo AA. Arthroscopic shoulder stabilization with suture anchors: technique, technology, and pitfalls. Clin Orthop Relat Res 2001; (390): 17-30.
[http://dx.doi.org/10.1097/00003086-200109000-00005] [PMID: 11550863]
] The idea of using a single anchor and adapt the open vertical apical suture technique described by S. Copeland [7Massoud SN, Levy O, Copeland SA. The vertical-apical suture Bankart lesion repair for anteroinferior glenohumeral instability. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al] 2002; (5): 481-5. Sep-Oct; 11
[PMID: 12378168.] [http://dx.doi.org/10.1067/mse.2002.126207]
] in the form of “purse- string” technique was first described in 2006 by O. Levy [8Levy OM. Purse-String Suture Technique: A New Method of Arthroscopic Shoulder Stabilization. Tech Shoulder Elbow Surg 2006; 7(2): 102-5.
[http://dx.doi.org/10.1097/00132589-200606000-00006]
] and was found to be at least as successful as multiple anchor techniques [9Levy O, Matthews T, Even T. The “purse-string” technique: an arthroscopic technique for stabilization of anteroinferior instability of the shoulder with early and medium-term results. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2007 2007; 23(1): 57-64.
[PMID: 17210428] [http://dx.doi.org/10.1016/j.arthro.2006.10.006]
]. Since then one more centre has published results using the “purse- string” technique to achieve successful arthroscopic shoulder stabilization [10Witney-Lagen C, Perera N, Rubin S, Venkateswaran B. Fewer anchors achieves successful arthroscopic shoulder stabilization surgery: 114 patients with 4 years of follow-up Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al] 201423 [Mar; 23];(1): 57-64. Epub 2013/11/26. eng
[PMID: 24268994.]
].

The purpose of this study is to review the recent literature and report the results of Reading Shoulder Unit regarding the arthroscopic “purse- string” technique.

MATERIALS AND METHOD

Surgical Technique [8Levy OM. Purse-String Suture Technique: A New Method of Arthroscopic Shoulder Stabilization. Tech Shoulder Elbow Surg 2006; 7(2): 102-5.
[http://dx.doi.org/10.1097/00132589-200606000-00006]
]

The patient is positioned in the beach chair position under general anaesthesia. The lateral decubitus position may be used, although we have found the beach chair position easier as it helps to bring the anteroinferior capsule superiorly and is useful as well in terms of ease of conversion to an open procedure. Examination under anaesthesia should be performed with side-to-side comparisons, and range of motion and the degree and direction of humeral head translation are documented according to the method of Cofield et al. [11Cofield RH, Nessler JP, Weinstabl R. Diagnosis of shoulder instability by examination under anesthesia. Clin Orthop Relat Res 1993; (291): 45-53.
[PMID: 8504613]
] The shoulder is prepared for surgery and draped in a sterile manner, and the bony landmarks are marked. The arm is positioned by using longitudinal traction of 8 to 10 lbs, in 30- to 40- of flexion. Lateral traction is applied by the assistant or by placing a kidney dish in the axilla.

The joint is entered with a standard 30- arthroscope from the posterior portal. An initial visualization is performed by insufflating 60 mL of air into the joint using a 20-mL syringe. This allows a quick assessment of the structures before pressurized fluid is introduced to the joint. An anterior portal is next established using an outside-in technique. An 18-gauge spinal needle is passed superior to subscapularis, and the needle is used to check that instruments will be easily able to reach the level of the anteroinferior labrum (6-o’clock position).

When this has been confirmed a definitive portal is established using an 8-mm commercially available clear cannula system. The arthroscopic pump is connected, and a systematic evaluation of the glenohumeral joint is performed to assess anterior labral detachment, capsular tears, superior labral and biceps anchor detachment, bony injuries including bony Bankart and Hill-Sacks lesions, rotator cuff pathology, and the inferior pouch to exclude a Humeral Avulsion of Glenohumeral Ligament lesion. It is important to also view from the anterior portal to assess bony loss adequately. Having confirmed the presence of a Bankart lesion, the next step is meticulous mobilization of the capsulolabral complex off the glenoid neck using an arthroscopic elevator. An Angled liberator is used to release the labrum at the 5- and 6-o’clock positions. A grasper or suture manipulator is used to assess the degree of release which is continued until satisfactory. Angled arthroscopic rasps and a 4.0-mm mechanical shaver are used to gently decorticate the anterior neck being mindful not to exacerbate any bony loss. It is useful to clip the shaver suction tubing at this stage to prevent accidental damage to the capsulolabral tissue. The next step is the placement of a suture anchor in the 4-o’clock position. We have used a bioabsorbable anchor with a polydioxanone suture material. The anchor is positioned at 45- to the frontal plane on the glenoid face on the edge of the cartilage surface. The main difference between standard techniques and the purse-string method is the technique of suture passage through both superior and inferior capsulolabral tissue from approximately 2- to 6-o’clock positions. The inferior suture limb is passed through the capsule at the 6-o’clock position Fig. (1). A penetrating grasper is passed through the capsule at the 6-o’clock position, and the suture is delivered into its jaws using a knot pusher. The knot pusher is also passed through the same anterior working portal. We have developed a penetrating grasper specifically for this application, the Sixter penetrating grasper (TAG Medical Products, Kibbutz Gaaton, Israel/ DepuyMitek, Warsaw, USA). The size of the capsule bite will ultimately determine the degree of capsular shift achieved. The superior suture limb is positioned at the 2-o’clock position, and the suture ends are tied. Once the suture is tied, the labrum forms a rolled free edge, and the anterior structures are snugged down onto the convex decorticated surface of the anterior glenoid neck. The capsule is drawn up from a south-to-north position addressing the laxity and restoring the Inferior Glenohumeral Ligament. The position of the anchor at 4-o’clock secures the capsular shift from south to north. As the glenoid is an elliptic-circular structure, applying an apical contracting suture in one area around the glenoid will create a circumferential capsular shift like a ‘purse-string` mechanism. Using this ‘purse-string technique,` a large surface area apposition between the capsule and the glenoid neck is created (and not only ‘spot welding`), as well as an anterior bumper with the mass of gathered tissue within the ‘purse-string` suture Fig. (2). Once the purse-string suture has been tied, the resultant “bumper^ of capsulolabral tissue is probed to ensure it is firmly fixed to the glenoid. A rotator interval closure may be performed at this stage if necessary. If necessary, an additional anchor may be placed further superior on the glenoid to supplement the repair.

Fig. (1)
The suture through the capsulolabral complex tightens the tissue in the same manner as the drawstring of a purse [8Levy OM. Purse-String Suture Technique: A New Method of Arthroscopic Shoulder Stabilization. Tech Shoulder Elbow Surg 2006; 7(2): 102-5.
[http://dx.doi.org/10.1097/00132589-200606000-00006]
].


Postoperative Managment [8Levy OM. Purse-String Suture Technique: A New Method of Arthroscopic Shoulder Stabilization. Tech Shoulder Elbow Surg 2006; 7(2): 102-5.
[http://dx.doi.org/10.1097/00132589-200606000-00006]
]

Postoperatively, the patient is immobilized in a sling with a body belt for 3 weeks with no external rotation permitted. At 3 weeks, the body belt is removed and pendulum exercises can commence. Formal mobilization from the sling occurs at 6 weeks when physiotherapy commences. Physiotherapy includes mobilization, proprioception rehabilitation, scapular stability, and rotator cuff strengthening. It is recommended that patients do not return to contact or overhead sports for 6 months.

Fig. (2)
A,B: MR Arthrogram showing soft tissue Bankart lesion (white arrow); C: arthroscopic view (white arrow);D: Post liberation (multiple arrows); E Final repair (white arrow)


Patients

The senior author has been using the purse-string technique for arthroscopic stabilization for many years. It has the advantage of being technically simpler, faster and cheaper, avoiding multiple suture anchors.

Between 2003 and 2013 a total of 193 patients were operated with median age 27 (range 15- 74) years old. Of them 142 (73.5%) were male and 3 (1.5%) had bilateral shoulder instability. The patient group included only those with anterior instability with a distinct history of trauma. The mean number of dislocations was 5 per patient (range, 1 to 11). Patients with no history of trauma, with multidirectional atraumatic instability or without a finding of Bankart-type lesions were excluded. Patients were followed up routinely at 3 weeks, 6 weeks, 3 months, and 6 months postoperatively and at final follow up.

Using the National Centre for Biotechnology Information PubMed database relevant studies reporting results of the “purse string” technique were identified.

RESULTS

Patients were followed up in the clinic for a minimum of 6 (range 6-24) months until discharged. Median follow up since surgery is 4.3 (range 1 to 9) years. Almost all patients (97%) returned to their sporting and leisure activities and all professional athletes went back to the same sport.

Overall 9 (4.7%) patients experienced recurrent instability symptoms at a median of 24 (range 6 to 36) months post-surgery. Three patients (1.6%) had recurrent subluxation and apprehension that was treated with physiotherapy. This happened at median of 21 (range 6- 26) months and in one of them, that was a professional athlete, occurred during a martial arts tournament when hit by another athlete. Six patients (3.1%) had recurrent dislocation requiring further surgery. Four of them sustained a new sports traumatic injury. Only one patient needed a Latarjet procedure and the rest were treated successfully with revision “purse-string” technique.

During literature research 1 paper was identified from a UK centre publishing similar results to ours. From 114 consecutive patients with anterior instability and a Bankart lesion treated with “purse string” failure rate was 6.1% at 4 years follow-up.

DISCUSSION

Over the last years arthroscopic surgery has made significant advances both in materials and techniques. This has led to similar long term results between open and arthroscopic surgery for anterior shoulder instability [12Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up. J Bone Joint Surg Am 2000; 82-A(7): 991-1003.
[http://dx.doi.org/10.2106/00004623-200007000-00011] [PMID: 10901314]
, 13Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM, Cole BJ, et al. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2013(5): 920-33. [May; 29]; Epub 2013/02/12. eng.
[PMID: 23395467] [http://dx.doi.org/10.1016/j.arthro.2012.11.010]
].

When using traditional arthroscopic techniques to stabilize the anterior labrum the number of suture anchors is reported as one of the most important factors affecting outcome. These techniques rely on using as many anchors as possible to “spot weld” the detached anterior labrum to the glenoid. As a result more “spots” lead to stronger repair and less than 2 anchors can cause failure [5Armangil M, Basat HC, Akan B, Karaduman M, Demirtaş M. Arthroscopic stabilization of anterior shoulder instability using a single anterior portal. Acta Orthop Traumatol Turc 2015; 49(1): 6-12. [eng.].
[PMID: 25803246]
, 14Ee GW, Mohamed S, Tan AH. Long term results of arthroscopic Bankart repair for traumatic anterior shoulder instability. J Orthop Surg 2011; 6: 28.
[http://dx.doi.org/10.1186/1749-799X-6-28] [PMID: 21672187]
, 15Provencher MT, Ghodadra N, Romeo AA. Arthroscopic management of anterior instability: pearls, pitfalls, and lessons learned. Orthop Clin North Am 2010; 41(3): 325-37.
[http://dx.doi.org/10.1016/j.ocl.2010.02.007] [PMID: 20497809]
].

The “Purse-String” technique (PST) is a different method to simultaneously address the Bankart lesion and anterior capsule laxity, using a double-loaded single suture anchor. The purpose of the PST is to repair the detached labrum, recreate the anterior bumper and shift the anterior- inferior capsule superiorly. These 3 repairs mimic the open vertical-apical suture technique [7Massoud SN, Levy O, Copeland SA. The vertical-apical suture Bankart lesion repair for anteroinferior glenohumeral instability. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al] 2002; (5): 481-5. Sep-Oct; 11
[PMID: 12378168.] [http://dx.doi.org/10.1067/mse.2002.126207]
] with the difference that in PST both Bankart repair and capsular shift are achieved on the glenoid side by extending the distances of suture limbs between 6- and 2-o’clock position [9Levy O, Matthews T, Even T. The “purse-string” technique: an arthroscopic technique for stabilization of anteroinferior instability of the shoulder with early and medium-term results. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2007 2007; 23(1): 57-64.
[PMID: 17210428] [http://dx.doi.org/10.1016/j.arthro.2006.10.006]
]. With the PST the anchor is less important than the “purse- string” sutures that create approximation of the anterior capsule, reduce laxity and improve proprioception. The role of the anchor at the 4 o’clock position in PST is to ensure that the capsule is shifted superiorly and the anterior bumper attaches to the glenoid. The only setback is that rehabilitation has to be conservative and movement is restricted for the first six weeks of healing [9Levy O, Matthews T, Even T. The “purse-string” technique: an arthroscopic technique for stabilization of anteroinferior instability of the shoulder with early and medium-term results. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2007 2007; 23(1): 57-64.
[PMID: 17210428] [http://dx.doi.org/10.1016/j.arthro.2006.10.006]
].

The senior author’s (O.L.) previous experience since 1998 that was published in 2006 [8Levy OM. Purse-String Suture Technique: A New Method of Arthroscopic Shoulder Stabilization. Tech Shoulder Elbow Surg 2006; 7(2): 102-5.
[http://dx.doi.org/10.1097/00132589-200606000-00006]
] and 2007 [9Levy O, Matthews T, Even T. The “purse-string” technique: an arthroscopic technique for stabilization of anteroinferior instability of the shoulder with early and medium-term results. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2007 2007; 23(1): 57-64.
[PMID: 17210428] [http://dx.doi.org/10.1016/j.arthro.2006.10.006]
] indicated very low recurrence rates of less than 6%. This continues to be evident in our latest results with a failure rate in the form of redislocation or instability symptoms of 4.7% (9 patients from 193). What is more important is that in 4 out of 9 patients recurrence was the result of a new violent incident (fall, motorcycle crush and martial arts injury).

One more centre in the UK uses the PST and has published similar results as ours. Failure rate for their series of 114 patients was 6.1% which is comparable to our 4.7%. These results are similar to other open and arthroscopic methods. In a recent review of 26 studies (1,781 patients) at mean of 11 years clinical follow-up recurrence of instability after arthroscopic techniques was 11% and after open 8% [13Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM, Cole BJ, et al. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2013(5): 920-33. [May; 29]; Epub 2013/02/12. eng.
[PMID: 23395467] [http://dx.doi.org/10.1016/j.arthro.2012.11.010]
]. (Table 1).

The “purse- string” suture, without an anchor in the glenoid, has also been used for arthroscopic rotator interval closure in symptomatic inferior shoulder instability. For this technique a single suture is passed from the superior glenohumeral ligament at the level of biceps tendon to the middle glenohumeral ligament overlying the subscapularis. This technique has been used to improve symptoms in multidirectional instability patients with more prominent antero- inferior instability symptoms. In 20 patients, at 2 years follow up, symptoms significantly improved and no re-dislocations were recorded [16Moon YL, Singh H, Yang H, Chul LK. Arthroscopic rotator interval closure by purse string suture for symptomatic inferior shoulder instability. Orthopedics PubMed PMID: Epub 2011/04/08 eng 20114 [Apr; 34];(3): 325-37.
[PMID: 21469638.] [http://dx.doi.org/10.3928/01477447-20110228-02]
].

Table 1
Relevant papers in literature.


CONCLUSION

The “purse-string” technique has been shown to be at least as effective for the treatment of anterior shoulder instability, with similar failure rates and high patient satisfaction. At the same time it has several advantages over multiple anchor “spot-welding” technique (SWT). The most obvious is cost since one third of anchors are used. At the same time PST is faster than SWT for the same reason. PST requires only one anterior portal and one cannula and is less traumatic to the anterior soft tissues. Finally, in case of failure the fact that only one anchor has been inserted makes revision simpler leaving space for revision anchors to be inserted [8Levy OM. Purse-String Suture Technique: A New Method of Arthroscopic Shoulder Stabilization. Tech Shoulder Elbow Surg 2006; 7(2): 102-5.
[http://dx.doi.org/10.1097/00132589-200606000-00006]
]. The “purse- string” suture can also be used in the very complex group of patients with multidirectional instability after careful selection and knowledge of the technique can lead to successful results in this difficult to treat condition [16Moon YL, Singh H, Yang H, Chul LK. Arthroscopic rotator interval closure by purse string suture for symptomatic inferior shoulder instability. Orthopedics PubMed PMID: Epub 2011/04/08 eng 20114 [Apr; 34];(3): 325-37.
[PMID: 21469638.] [http://dx.doi.org/10.3928/01477447-20110228-02]
].

LIST OF ABBREVIATIONS

PST  = “purse-string” technique
SWT  = “spot-welding” technique

CONFLICT OF INTEREST

The manuscript has been approved by all authors and is not under the consideration for publication elsewhere and that, if accepted, will not be published elsewhere in the same form, in English or in any other language, without the written consent of the publisher. We have no conflicts of interest to disclose.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Bankart AS. Recurrent or Habitual Dislocation of the Shoulder-Joint. BMJ 1923; 2(3285): 1132-3.
[http://dx.doi.org/10.1136/bmj.2.3285.1132] [PMID: 20771383]
[2] Perthes G. Über Operationen bei habitueller Schulterluxation. Dtsch Z Chir 1906; 56: 149-51.
[3] 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 : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2004 [May;20];5: 456-62. Epub 2004/05/04. eng.
[PMID: 15122134] [http://dx.doi.org/10.1016/j.arthro.2004.03.001]
[4] Sperling JW, Smith AM, Cofield RH, Barnes S. Patient perceptions of open and arthroscopic shoulder surgery. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 20074 [ Apr 23];: 361-6. Epub 2007/04/10. eng.
[PMID: 17418327] [http://dx.doi.org/10.1016/j.arthro.2006.12.006]
[5] Armangil M, Basat HC, Akan B, Karaduman M, Demirtaş M. Arthroscopic stabilization of anterior shoulder instability using a single anterior portal. Acta Orthop Traumatol Turc 2015; 49(1): 6-12. [eng.].
[PMID: 25803246]
[6] Cole BJ, Romeo AA. Arthroscopic shoulder stabilization with suture anchors: technique, technology, and pitfalls. Clin Orthop Relat Res 2001; (390): 17-30.
[http://dx.doi.org/10.1097/00003086-200109000-00005] [PMID: 11550863]
[7] Massoud SN, Levy O, Copeland SA. The vertical-apical suture Bankart lesion repair for anteroinferior glenohumeral instability. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al] 2002; (5): 481-5. Sep-Oct; 11
[PMID: 12378168.] [http://dx.doi.org/10.1067/mse.2002.126207]
[8] Levy OM. Purse-String Suture Technique: A New Method of Arthroscopic Shoulder Stabilization. Tech Shoulder Elbow Surg 2006; 7(2): 102-5.
[http://dx.doi.org/10.1097/00132589-200606000-00006]
[9] Levy O, Matthews T, Even T. The “purse-string” technique: an arthroscopic technique for stabilization of anteroinferior instability of the shoulder with early and medium-term results. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2007 2007; 23(1): 57-64.
[PMID: 17210428] [http://dx.doi.org/10.1016/j.arthro.2006.10.006]
[10] Witney-Lagen C, Perera N, Rubin S, Venkateswaran B. Fewer anchors achieves successful arthroscopic shoulder stabilization surgery: 114 patients with 4 years of follow-up Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al] 201423 [Mar; 23];(1): 57-64. Epub 2013/11/26. eng
[PMID: 24268994.]
[11] Cofield RH, Nessler JP, Weinstabl R. Diagnosis of shoulder instability by examination under anesthesia. Clin Orthop Relat Res 1993; (291): 45-53.
[PMID: 8504613]
[12] Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of anterior-inferior glenohumeral instability. Two to five-year follow-up. J Bone Joint Surg Am 2000; 82-A(7): 991-1003.
[http://dx.doi.org/10.2106/00004623-200007000-00011] [PMID: 10901314]
[13] Harris JD, Gupta AK, Mall NA, Abrams GD, McCormick FM, Cole BJ, et al. Long-term outcomes after Bankart shoulder stabilization. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2013(5): 920-33. [May; 29]; Epub 2013/02/12. eng.
[PMID: 23395467] [http://dx.doi.org/10.1016/j.arthro.2012.11.010]
[14] Ee GW, Mohamed S, Tan AH. Long term results of arthroscopic Bankart repair for traumatic anterior shoulder instability. J Orthop Surg 2011; 6: 28.
[http://dx.doi.org/10.1186/1749-799X-6-28] [PMID: 21672187]
[15] Provencher MT, Ghodadra N, Romeo AA. Arthroscopic management of anterior instability: pearls, pitfalls, and lessons learned. Orthop Clin North Am 2010; 41(3): 325-37.
[http://dx.doi.org/10.1016/j.ocl.2010.02.007] [PMID: 20497809]
[16] Moon YL, Singh H, Yang H, Chul LK. Arthroscopic rotator interval closure by purse string suture for symptomatic inferior shoulder instability. Orthopedics PubMed PMID: Epub 2011/04/08 eng 20114 [Apr; 34];(3): 325-37.
[PMID: 21469638.] [http://dx.doi.org/10.3928/01477447-20110228-02]

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Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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