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Arthroscopic Inferior Capsular Shift Long-Term Follow-up
Abstract
Neer and Foster's open inferior capsular shift to treat acquired cases of anteroinferior shoulder instability due to an overstretched and redundant capsule is described with good results. Recently, new arthroscopic techniques were described to manage this problem.
To assess the results of a new arthroscopic reinforced inferior capsular shift technique based on Neer and Foster's open inferior capsular shift.
Case series; Level of evidence, 4.
This new technique of arthroscopic inferior capsular shift was used to treat 108 patients with anteroinferior shoulder instability due to capsular redundancy as confirmed clinically and during arthroscopy. It reduces the size of the redundant capsular pouch and reinforces the thinned-out capsule. Intraoperatively, patients with associated labral tears (n = 25) and patients with open rotator intervals (n = 8) were excluded, and only 75 patients with pure capsular redundancy were included in this study.
Patients were followed for a minimum of 7 years. All 75 patients had patulous and redundant capsules. Three patients (4.0%) had a redislocation after a significant trauma. The range of motion preoperatively was 168.1° ± 7.5° in forward elevation, 64.7° ± 7.9° in external rotation, and T5.0 ± T0.8 in internal rotation. Postoperatively, it was 167.2° ± 5.8° in forward elevation, 59.95° ± 4.9° in external rotation, and T7.1 ± T1.0 in internal rotation. The American Shoulder and Elbow Surgeons (ASES) (70.76 to 97.53; P < .001), Constant (90.02 to 99.24; P < .001), and University of California, Los Angeles (UCLA) (21.97 to 33.84; P < .001) scores demonstrated significant improvement postoperatively.
This novel technique of arthroscopic capsular shift addresses the problem of capsular redundancy present in many cases of anteroinferior shoulder instability. It tries to achieve a capsular shift based on the principles of Neer. The long-term results are very good.
... Ahmad et al. [6] indicated that a redundancy of the anteromedial capsule of the shoulder persists despite proper tensioning of the capsule and repair of the Bankart lesion during anteroinferior capsular shift. Associated capsular laxity or redundancy may partially explain the variable outcome of arthroscopic procedures in terms of stability [25,26]. ...
... The most common surgical method is a Bankart repair, in which the detached labrum and anterior shoulder capsule are refixed to the anteroinferior articular margin of the glenoid (10). In atraumatic shoulder instability, surgery aims to tighten the inferior shoulder capsule (11). The concomitant lesions can be treated in the same operation, according to the surgeon's discretion and the evaluation of the lesion's clinical relevance. ...
Background and aims:
Shoulder capsular surgery is nowadays usually performed arthroscopically, and the proportion of arthroscopic method has rapidly increased during the last two decades. We assessed the incidence of shoulder capsular surgery procedures in Finland between 1999 and 2008.
Material and methods:
We gathered the shoulder capsular surgery procedures for all kinds of shoulder instability in Finland between 1999 and 2008 from National Hospital Discharge Register and limited the patient material to include only certain diagnosis (International Classification of Diseases, 10th Edition) and Nordic Medico-Statistical Committee procedure code combinations. We analyzed the data in the whole country, between different age groups, and in university hospital districts.
Results:
The total incidence of shoulder capsular surgery procedures in Finland increased from 17 to 33 per 100,000 person-years. The incidence of arthroscopic procedures increased from 11 to 30 per 100,000 person-years and the proportion of arthroscopic procedures increased from 63% to 92% between years 1999 and 2007. The incidence of shoulder capsular surgery procedures increased on average around 90% in almost all age groups and particularly in the older age groups. We observed no significant geographical variation between university hospital districts.
Conclusion:
The incidence of shoulder capsular surgery procedures increased on average round 90% in almost all age groups. It seems to be difficult to support the rapidly increased rates of shoulder capsular surgery procedures or the arthroscopic method based on scientific evidence. While also older patients are treated with shoulder capsular surgery, well-defined indications for surgical intervention are needed so that the operations are conducted for the symptomatic patients benefitting most regardless of patients' age.
... The predominance of female gender in ACR(+) may therefore be explained by a higher prevalence of general joint laxity criteria in the ACR(+) population. In contrast, Fleega and El Shewy [18] reported a series of 75 patients presenting with a capsular redundancy in a non-MDI context. The population constituted of fewer females but presented with general joint laxity in 30 %. ...
Purpose
There is a paucity of data detailing management of anterior capsular redundancy (ACR) when using the Latarjet procedure for unidirectional instability. This study aimed to describe the surgical management and to assess the clinical profile of patients presenting with anterior capsular redundancy [ACR(+)] with anterior shoulder instability.
Methods
Seventy-seven patients who had a Latarjet procedure were followed for a 55-month period. Per-operative ACR was assessed during surgery. ACR was considered present if the inferior capsular flap of a Neer T-shaft capsulorrhaphy was able to cover the superior capsular flap with the arm in the neutral position. Patients with ACR(+) received an additional Neer capsulorrhaphy, while patients with ACR(−) did not. This per-operative finding was correlated with demographics, clinical, radiological pre-operative data and surgical outcome.
Results
Patients presenting with a per-operative ACR(+) were significantly associated with a sulcus sign (P 4 (P
... Fleega and El Shewy [81] reported very good long-term results (7 years) of arthroscopic inferior capsular shift; they described a significant improvement in ASES, Constant-Murley and UCLA scores, complete recovery of shoulder motion, and a 4 % rate of redislocation. Voigt et al. [82] performed arthroscopic anterior-inferior and posteriorinferior capsular plication and RI closure in nine young overhead athletes with persistent, symptomatic MDI and reported excellent to good Rowe and Constant-Murley scores in nine patients (ten shoulders) at 39 months; however, three patients had to reduce their level of sport participation. ...
Multidirectional instability (MDI) of the shoulder is a condition where the dislocation occurs in more than one direction with minimal or no causative trauma. Its pathoanatomy is complex and characterized by a redundant capsule, resulting in increased glenohumeral joint volume. The fact that several further factors may contribute to symptom onset complicates the diagnosis and hampers the identification of a therapeutic approach suitable for all cases. There is general agreement that the initial treatment should be conservative and that surgery should be reserved for patients who have not responded to an ad hoc rehabilitation program. We review the biomechanics, clinical presentation, and treatment strategies of shoulder MDI.
... However, clinical studies reported success rates of 80 to 97% after open capsular shift (25,34,35,57). High success rates, ranging between 68 and 100%, have also been reported after arthroscopic capsular shift (58)(59)(60). A recent systematic review (61) comparing open capsular shift versus arthroscopic capsular plications showed that arthroscopic capsular plications yield comparable results to open capsular shift with regard to recurrent instability, return to sport, loss of external rotation, and overall complications. ...
Generalized joint laxity and shoulder instability are common conditions that exhibit a wide spectrum of different clinical forms and may coexist in the same patient. Generalized joint laxity can be congenital or acquired. It is fundamental to distinguish laxity from instability. Laxity is a physiological condition that may predispose to the development of shoulder instability. A high prevalence of generalized joint laxity has been identified in patients with multidirectional instability of the shoulder. Multidirectional instability is defined as symptomatic instability in two or more directions. The diagnosis and treatment of this condition are still challenging because of complexities in its classification and etiology. These complexities are compounded when multidirectional instability and laxity exist in the same patient. With an improved understanding of the clinical symptoms and physical examination findings, a successful strategy for conservative and/or surgical treatments can be developed. Conservative treatment is the first-line option. If it fails, different surgical options are available. Historically, open capsular shift has been considered the gold standard in the surgical management of these patients. Nowadays, advanced arthroscopic techniques offer several advantages over traditional open approaches and have shown similar outcomes. The correct approach to the management of failed stabilization procedures has not been yet defined.
Purpose of Review
Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD).
Recent Findings
Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results.
Summary
In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.
Multidirectional instability (MDI) is an uncommon underdiagnosed shoulder condition characterized by symptomatic shoulder instability causing pain, apprehension, and discomfort in more than one direction. Several predisposing and etiologic factors have been described, including congenital hyperlaxity, repetitive microtrauma, muscle imbalance, and anatomic factors such as reduced glenoid concavity. In practice, MDI results from a combination of soft tissue laxity, scapular dyskinesis, and altered muscular activity, allowing the glenoid to point downward, ultimately predisposing the humeral head to escape inferiorly. The diagnosis is almost solely clinical, based on patient’s history and clinical examination, as imaging studies may be interpreted as completely normal. At presentation, conservative management, based on rehabilitating the scapulohumeral dyskinesia and the rotator cuff, for a minimum of 6 months is generally recommended. If this fails, surgery is indicated. The most commonly performed procedure at present is arthroscopic capsular plication (ACP), with sutures applied so as to fold the posterior, inferior, and anterior capsule over itself, thus reducing the joint volume. The present chapter presents the basic evidence, clinical results, and a step-by-step easy and reproducible surgical technique for ACP in MDI, with the tips and tricks developed by the main author.
The 708 B.C. Ancient Greek Olympic games introduced for the first time the discus and javelin throw, and the concept of the overhead throwing athlete was born. Hammer throw and shot put would later be added to the Olympic games. Much like throwing a baseball, success in each of these events requires transmission of tremendous energy through the kinetic chain, translating force from the legs, through the trunk, the scapula, and into the glenohumeral joint. To achieve maximal performance, a balance must take place in the throwing shoulder between soft tissue laxity to tolerate the forces of throwing and stability to prevent injury and subluxation of the humeral head. This makes diagnosing and treating shoulder instability in the overhead athlete a challenging task for the practicing orthopedic surgeon. Here, we will review the biomechanics, management, rehabilitation, and surgical treatment for shoulder instability in overhead track and field athletes.
Shoulder instability encompasses a wide spectrum of clinical manifestations that range from painful hyperlaxity to chronic locked shoulder dislocations. Correct diagnosis is critical to establish an effective treatment strategy. The biomechanics, clinical presentation, and management of shoulder instability are discussed and reviewed.
Capsular instability occurs when the glenohumeral joint capsule becomes so mechanically compromised that the remaining static and dynamic joint stabilizers cannot prevent symptomatic glenohumeral subluxation and/or dislocation. Most patients do not have a history of trauma and complain of activity-related pain. Physical examination identifies laxity, which should not be confused with instability. The clinician must distinguish between multidirectional instability with or without hyperlaxity, unidirectional instability with hyperlaxity, and glenohumeral hyperlaxity. Magnetic resonance imaging or arthrography may be used to evaluate the glenohumeral soft tissues and rule out the presence of other pathology that may contribute to glenohumeral instability. The objective of any rehabilitation, repair, or reconstruction is to impart sufficient stability to static and/or dynamic stabilizers to eliminate symptomatic subluxation and dislocation. A 6-month trial of physiotherapy is common. Examination under anesthesia determines the magnitudes and directions of laxity, which directs surgical treatment. Arthroscopic capsulolabral plication with or without interval closure is the mainstay of surgical stabilization. This technique shortens and reinforces the capsule while reducing capsular volume. While uncommon, trauma is the major risk factor for recurrent instability.
Inferior/multidirectional instability of the shoulder is a complex condition, which is diffi cult to diagnose and manage, and there is no good evidence regarding treatment. A case series of 40 shoulders (36 patients) with inferior/multidirectional instability of the shoulder referred to the author is presented. Instability was found to be due to inherent laxity of the shoulder capsule or due to repetitive overhead activities. Patients were evaluated clinically by examination, stress and apprehension tests, traction radiographs and further examination at the time of surgery. Arthrograms were not found to be benefi cial. Surgery was recommended in patients with disability persisting for more than 1 year not improved by conservative methods to strengthen the rotator cuff. The surgical technique of an inferior capsular shift through an anterior or posterior approach was used for all patients; a satisfactory outcome was seen in all but one patient.
Both open and arthroscopic Bankart repair are established procedures in the treatment of anterior shoulder instability. While the open procedure is still considered as the "golden standard" functional outcome is supposed to be better in the arthroscopic procedure. The aim of this retrospective study was to compare the functional outcome between open and arthroscopic Bankart repair.
In 199 patients a Bankart procedure with suture anchors was performed, either arthroscopically in presence of an detached, but not elongated capsulolabral complex (40) or open (159). After a median time of 31 months (12 to 67 months) 174 patients were contacted and agreed to follow-up, 135 after open and 39 after arthroscopic Bankart procedure.
Re-dislocations occurred in 8% after open and 15% after arthroscopic Bankart procedure. After open surgery 4 of the 11 re-dislocations occurred after a new adequate trauma and 1 of the 6 re-dislocations after arthroscopic surgery. Re-dislocations after arthroscopic procedure occurred earlier than after open Bankart repair. An external rotation lag of 20 degrees or more was observed more often (16%) after open than after arthroscopic surgery (3%). The Rowe score demonstrated "good" or "excellent" functional results in 87% after open and in 80% patients after arthroscopic treatment.
In this retrospective investigation the open Bankart procedure demonstrated good functional results. The arthroscopic treatment without capsular shift resulted in a better range of motion, but showed a tendency towards more frequently and earlier recurrence of instability. Sensitive patient selection for arthroscopic Bankart repair is recommended especially in patients with more than five dislocations.
The purpose of this study was to compare the percentage of glenohumeral intracapsular volume reduction after open inferior capsular shift and arthroscopic thermal capsulorrhaphy. Twelve matched, fresh-frozen cadaveric shoulders were used for the study. Intraarticular glenohumeral volume measurements were obtained by injecting a viscous fatty acid sulfate solution into the joint. In the 6 right shoulders, a standard anterior-inferior capsular shift was performed, and in the 6 matching left shoulders, an arthroscopic thermal capsular shrinkage was performed. After the procedures, the capsular volumes were re-measured. The open inferior shift procedure resulted in a mean decrease in glenohumeral volume of 50.2% (range, 43%-56%). Arthroscopic thermal capsulorrhaphy decreased shoulder intraarticular volume by a mean of 29.7% (range, 26%-36%). Both the open capsular shift and arthroscopic thermal shrinkage procedures produced well-documented volumetric reductions in the shoulder capsules. The open shift reduced intraarticular shoulder volume significantly more than arthroscopic thermal capsular shrinkage.
Fragestellung: Ziel dieser prospektiven Studie war die Darstellung der Ergebnisse der arthroskopischen transglenoidalen Naht nach Morgan bei der rezidivierenden posttraumatischen vorderen Schulterinstabilität.
Methode: Es wird über 30 Patienten, die in der oben beschriebenen Weise operiert wurden, berichtet. Der Mindestnachuntersuchungszeitraum betrug 2 Jahre, das mittlere Follow-up 36 Monate. Das Durchschnittsalter der 23 Männer und 7 Frauen war 27,5 Jahre. Die durchschnittliche präoperative Reluxationsrate lag bei 6,35. Alle Patienten wurden postoperativ 3 Wochen immobilisiert. Die Nachuntersuchungen erfolgten durch einen unabhängigen Beobachter anhand des Rowe-Scores.
Ergebnisse: Nach 3 Jahren beklagten 5 Patienten (17%) eine oder mehrere Reluxationen. Alle erneuten Luxationen traten zwischen dem 6 und 24 postoperativen Monat auf. Insgesamt hatten 80% ein gutes oder sehr gutes Ergebnis. 83,4% der Operierten berichteten über keine oder nur eine leichte Einschränkung der Sportfähigkeit. Die Rezidivpatienten hatten bezüglich der präoperativen Reluxationen einen Median von 8,6 gegenüber den postoperativ Schulterstabilen von 5,9. Dieser Unterschied ist statistisch signifikant.
Schlußfolgerung: Sowohl unsere Ergebnisse als auch die Angaben in der Literatur zeigen eine deutlich höhere Reluxationsrate nach arthroskopischer Schulterstabilisierung als die klassische offene Bankartoperation. Wenn man sich dennoch für dieses Verfahren entscheidet, sollte es sich um Patienten mit einer unidirektionalen, vorderen, posttraumatischen Schulterinstabilität ohne wesentlich erweiterte Gelenkkapsel- und bänder und ohne gehäufte präoperative Reluxationen handeln.
Many studies report the results of arthroscopic stabilization for recurrent shoulder instability, with widely variable recurrence rates; however, there are very few reports of the use of these techniques in acute first-time dislocations. We report the clinical outcomes of 17 patients who had arthroscopic stabilization using a transglenoid suture technique for acute primary dislocation. The surgery took place between March 1992 and March 1994 and, to date, there has been one recurrent dislocation (6%) and no recurrent subluxation. There were no major complications, although a number of patients found the knot tied over the infraspinatus fascia to be uncomfortable until it resorbed. All patients examined had normal power and range of motion, and a clinically stable shoulder. All 16 patients without recurrence were satisfied with their result. Nine patients returned to sports at the same or higher level, including such vigorous contact sports as Australian Rules football and rugby. Three patients did not return to the same level of sporting activity because of lack of confidence in the shoulder or a fear of dislocation despite no clinical evidence of instability. Five patients reported a lack of confidence in the shoulder without clinical evidence of instability. We suggest that arthroscopic stabilization with transglenoid sutures or a suture anchor technique is a reasonable option for the athlete with an acute primary shoulder dislocation who wishes to return to sports.
To quantify the relationship between the amount of shoulder capsule imbricated with a simple stitch and the degree of glenohumeral volume reduction in a multidirectional instability model. Secondary purposes were to identify the number of arthroscopic plication stitches required to reduce the shoulder volume equal to that of an open lateral-based inferior capsular shift and to compare volume reductions between suture anchor and suture-only capsular plication stitches.
Controlled laboratory study.
Twelve fresh-frozen cadaveric shoulders (mean age, 64.4 years) were dissected to the level of the rotator cuff. A viscous liquid was injected into each joint, and measurements were taken before and after six 1-cm arthroscopic capsular plication stitches were performed. The sizes of the capsular plications were measured to quantify the amount of capsule imbricated with each simple stitch. A repeated random-intercept regression model was fitted for each outcome, with significance set at P = .05.
There was a near-linear relationship, with each 1 cm of total plication equaling 10% volume reduction up to 4.0 cm. After this, each additional 1-cm plication stitch resulted in 2% to 6% more reduction (mean, 4%). Five simple plication stitches reduced the volume by 52% in the suture anchor group and 49% in the suture-only group. The suture anchor achieved 3% greater volumetric reduction than the suture-only plication stitches, but this effect was not statistically significant (P = .06). Conclusion/
A 1-cm capsular plication stitch results in a roughly 10% volume reduction of the glenohumeral joint. Five simple capsular plication stitches result in a volume reduction equivalent to an open lateral-based capsular shift.
Recurrent instability after surgical stabilization of the shoulder is uncommon. Although results of open revision stabilization procedures have been reported, only 3 studies have evaluated the outcome of arthroscopic revision surgery.
To analyze results of arthroscopic revision anterior shoulder reconstruction at the authors' institution.
Case series; Level of evidence, 4.
Chart review identified 18 shoulders that had arthroscopic revision anterior shoulder reconstruction at the Southern California Orthopedic Institute between November 4, 1997, and May 14, 2002. Anterior reconstruction of the shoulder was performed using suture anchors and nonabsorbable sutures. In most patients, posterior capsular plication was also performed; in 1 patient, closure of the rotator interval was performed. Sixteen shoulders in 15 patients were examined and 1 patient who required revision surgery was interviewed at a mean of 38 months (range, 24-67 months) after arthroscopic revision anterior shoulder reconstruction. The patient population consisted of 13 men and 3 women whose age at surgery was between 17 and 55 years (mean, 30 years; SD, 11.9 years). Patient satisfaction, the Simple Shoulder Test, and the Rowe scale were used to measure outcome.
Prior surgeries included 10 arthroscopic procedures in 9 shoulders and 10 open procedures in 8 shoulders. In this study group, 1 patient dislocated his shoulder 4 months after arthroscopic revision anterior shoulder reconstruction during an altercation and subsequently underwent a Bristow procedure. Of the remaining cases, none of the 16 shoulders had recurrence of dislocation or subluxation; all 15 patients were satisfied with their revision surgeries. Among this group, the Simple Shoulder Test responses improved from 8.3 yes responses to 11.3 after arthroscopic revision anterior shoulder reconstruction (P < .05). Using the Rowe scale, there were 9 excellent, 4 good, and 3 fair results. Mean Rowe score at follow-up was 83.8 (range, 55-100; SD, 14.7) for these 16 shoulders.
In this series, 94% of shoulders were stable after arthroscopic revision anterior shoulder reconstruction, and there were a high number of good and excellent outcomes. Results suggest arthroscopic revision anterior shoulder reconstruction using suture anchors is a viable treatment alternative for patients with failed anterior shoulder reconstructions.
Thirty-eight patients (forty-three shoulders) who had disabling multidirectional instability of the shoulder were managed with an inferior capsular-shift procedure through an anterior approach. All of the patients were followed for a minimum of two years. The postoperative range of motion of the shoulders was well maintained. The mean forward elevation was 172 degrees; external rotation, 77 degrees; and internal rotation, to the level of the eighth thoracic vertebra. Four patients (four shoulders) had recurrence of symptomatic and disabling multidirectional instability, but thirty-nine (91 per cent) of the shoulders continued to function well with no instability. Nine patients (24 per cent) continued to have episodes of apprehension, which correlated with the residual inferior and posterior translations found at the postoperative physical examination. Thirty-four patients (thirty-nine shoulders) stated that they were subjectively satisfied with the status of the shoulder, but four patients, in whom the instability had recurred, were not satisfied. Thirty-seven (86 per cent) of the shoulders were judged to have been improved by the procedure, the initial postoperative stability had been maintained, and the result had not deteriorated with time. Six shoulders, however, including the four with recurrent instability, were thought by the patient to have deteriorated with the increased duration of follow-up. It was our experience that if non-operative treatment of multidirectional instability of the shoulder failed, the inferior capsular-shift procedure provided satisfactory objective and subjective results. Failures and recurrences of symptomatic instability occurred early in the postoperative period. There appeared to be no deterioration of the results with follow-up to seventy-one months.
Multidirectional and inferior instability of the shoulder is not rare. Etiological factors include various combinations of (a) repetitive injuries, (b) inherent joint laxity, and (c) one or more major injuries. It is seen in athletic and active patients without generalized joint laxity and as well in sedentary patients with hypermobile joints. Standard operations for unidirectional anterior or posterior dislocations fail to correct multidirectional instability because they do not correct inferior instability and they may displace the head in fixed subluxation to the opposite side leading to severe arthritis ("arthritis of dislocations"). Proper detection depends on suspecting its possibility in all types of patients and in a wide age range as well. Helpful signs include the sulcus sign, positive apprehension test in multiple directions, stress roentgenograms and fluoroscopy, and evaluations under anesthesia. Arthroscopy may be helpful in doubtful cases, but the findings require clinical interpretation. Selection of patients with multidirectional instability for surgery is extremely difficult because it requires not only great care in determining all directions of instability and planning the repair but also determining the motivation of the patient and excluding the possibility of some other condition being present that is causing pain rather than the joint laxity. The results of inferior capsular shift have continued to withstand the test of time and, though it is more difficult than standard procedures, is considered a very helpful procedure in the treatment of these difficult lesions. The principle is to reduce capsular laxity on all three sides by shortening and reinforcing and to reduce the joint volume.(ABSTRACT TRUNCATED AT 250 WORDS)
Sixty-eight shoulders in 63 athletic patients with anterior-inferior glenohumeral instability underwent an anterior-inferior capsular shift procedure. Shoulders with glenoid fractures, predominantly posterior instability, or routine, unidirectional anterior instability were not included in this study. There were 42 men and 21 women, with an average age of 23 years. Forty-two repairs were performed on the dominant arm. All 31 overhead throwing athletes had their dominant arms repaired. Forty-six shoulders had histories of recurrent anterior dislocations, while 22 shoulders had recurrent subluxation. All 68 shoulders had an anterior-inferior capsular shift, tailored to the degree of laxity found; in addition, 21 had repair of a Bankart lesion. Forty-two patients were rated excellent (67%), 17 good (27%), 2 fair (3%), and 1 poor (3%). Fifty-eight of 63 (92%) patients returned to their major sports, 47 (75%) at the same competitive levels. Only 5 of 10 elite throwing athletes returned to their prior competitive levels. Loss of external rotation averaged 7 degrees. Two patients (2.9%) re-dislocated postoperatively, after violent falls.
Ten consecutive patients with involuntary multidirectional instability who did not respond to rehabilitative treatment were managed by an arthroscopic modification of the inferior capsular shift procedure described by Altcheck and Warren. All patients were reviewed 1-3 years postoperatively using both the satisfactory/unsatisfactory system of Neer and the Bankart rating scale of Rowe. The average Bankart score was 90 (range 75-95) and all patients had a satisfactory result according to the Neer system. The arthroscopic capsular shift procedure appears to provide satisfactory results in the management of selected patients with multidirectional instability as evidenced in this preliminary report.
We evaluated the comparability of four commonly used shoulder scoring systems in the United States. Fifty-two patients had 53 shoulder stabilization procedures. Surgical procedures included 34 open Bankart-type repairs, 15 capsular shifts, and 4 arthroscopic stabilizations. Results were assessed using the following scales: 1) Rowe, 2) modified-Rowe, 3) University of California at Los Angeles, and 4) the pre-1994 American Shoulder and Elbow Surgeons scale. No consensus has been reached on the relative value of these systems. We observed significant variations using these systems. A majority of our patients (85%) had excellent results when the University of California at Los Angeles scoring system was used. However, only 38% of the patients had excellent results when the modified-Rowe scale was used. Overall, good or excellent results were observed in 89% to 95% of the patients using these four scoring systems. The University of California at Los Angeles score correlated poorly with the other systems. Interrater reliability between the four systems was poor. Generalized results of an investigation can be biased based on the selection of a scoring system. The lack of a widely accepted scoring system for the shoulder limits comparison of management for shoulder conditions. Thus, a widely accepted shoulder scoring system is needed.
Aim of this study was to evaluate the results after athroscopic transglenoidal stabilization in patients with anterior posttraumatic shoulder instability.
30 patients with posttraumatic anterior shoulder instability were prospectively observed for a mean of 36 months (24-56) after an athroscopic stabilization has been performed. The operative technique was carried out as described by Morgan with use of transglenoidal sutures to repair the labrum.
All patients had a Bankart lesion and a Hill-Sachs defect. According to the criteria of Rowe, 24 patients (80%) had good or excellent results and 1 patient (3%) was graded as fair. 5 patients (17%) developed recurrent instability 6-24 months postoperatively so they had failed results. 83.4% had no or little limitation in sports activity. Sex, age or grade of activity had no influence on the result concerning stability. The mean preoperative dislocation rate was 8.6 for the failures and 5.9 for the stable results (p < 0.05).
The results of arthroscopic stabilization of the shoulder are inferior to the classical open repair. It should only be performed in patients with unidirectional, posttraumatic anterior shoulder instability without capsulaligamentous hyperlaxity or multiple resdislocations.
Eighty-two patients with traumatic anterior shoulder instability were treated with an arthroscopic transglenoid multiple suture technique (Caspari's method) and followed-up for more than 2 years. A retrospective analysis of the clinical outcome was performed to determine the factors related to poor results. The mean age at operation was 21 years (range, 13 to 50 years) and the mean follow-up period was 40 months (range, 24 to 70 months). According to the status of the ligament-labrum complex and the glenoid bone defect, the Bankart lesions were classified into five types arthroscopically. There were 21 shoulders of type 1, 33 shoulders of type 2, 22 shoulders of type 3, and 6 shoulders of type 5. Twenty-four of the patients played contact sports before the operation. The clinical outcome was assessed by Rowe's criteria (1978). To analyze the factors related to a poor outcome, a multivariate analysis was done to assess the influence of 12 clinical factors (age at operation, age at first dislocation, sex, dominant side, disease duration, number of dislocations, sporting activity before operation, inferior joint laxity, thickness of the ligament-labrum complex, type of Bankart lesion, number of sutures, and method of suture fixation). Fifty-five of 82 patients had an excellent outcome, 14 had a good result, and 13 had a poor result. According to postoperative instability, redislocation was seen in 13 patients (16%), resubluxation in 2 patients (2%), with a recurrence rate of 18%. The mean limitation of external rotation at 90 degrees abduction was 6.0 degrees (range, 0 degrees to 30 degrees), and there was a 10 degrees loss of external rotation in 10 patients. The factors significantly related to recurrence were a type 3 Bankart lesion, playing contact sports preoperatively, a thin ligament-labrum complex, and repair with less than four sutures. In conclusion, a 18% rate of recurrence is not acceptable. To obtain a better clinical outcome, very careful selection of patients for this technique is necessary. Our analysis of the factors related to a poor outcome may help to decide what the proper indications are for this technique.
Multidirectional instability of the shoulder, described by Neer and Foster, has been treated surgically with the inferior capsular shift procedure. The small number of reports on mid-term outcomes indicate that good to excellent results have been obtained in 75% to 100% of cases. Arthroscopic treatment of multidirectional instability has been previously described. The purpose of this study was to review the results of the arthroscopic capsular shift procedure with a minimum follow-up of 2 years. A retrospective study was performed on 25 patients who underwent an arthroscopic capsular shift performed with the transglenoid technique between January 1990 and December 1993. All patients had earlier not responded to an extensive course of physical therapy. Excluded from the study were patients who had undergone a previous arthroscopic capsular shift or any other procedure, arthroscopic or open, for the shoulder. Average patient age was 26.4 years. There were 20 male and 5 female patients. Sixteen of the affected shoulders involved the dominant extremity. All patients had a history of asymptomatic subluxation that slowly progressed to symptomatic subluxation. Eleven patients had a history of dislocation. Thirteen patients were athletes who were symptomatic in their chosen sport, whereas the other patients were symptomatic in activities of daily living. All patients were examined while they were under anesthesia and had positive results on the sulcus test in abduction with associated anterior instability, posterior instability, or both. Follow-up evaluation was performed with patient interview and examination. All 25 patients were available for follow-up, which occurred an average of 60 months (range 36 to 80 months) after operation. Three patients had episodes of instability after the operation. The average Bankart score was 95 (range of 50 to 100). All but 1 patient had regained full symmetric range of motion by follow-up. Twenty-one (88%) patients had a satisfactory result according to the Neer system. Results of treatment with the arthroscopic capsular shift procedure for multidirectional instability of the shoulder appear to be comparable to those of the open inferior capsular shift.
Neer and Foster previously described the inferior capsular shift procedure for treating multidirectional instability of the shoulder and reported preliminary results that were quite satisfactory. The purpose of our study was to perform a longer-term follow-up evaluation of the efficacy of the inferior capsular shift procedure for treating multidirectional instability of the shoulder.
An inferior capsular shift procedure was used to treat multidirectional instability of the shoulder in forty-nine patients (fifty-two shoulders). All patients had failed to respond to an exercise program. In this series, the operative approach (anterior or posterior) was based on the major direction of the instability, as determined by the preoperative history and physical examination and as verified by examination with the patient under anesthesia. In all of the patients, the inferior capsular shift was the primary attempt at operative stabilization. The repair consisted of a lateral-side (or humeral-side) shift of the capsule to reduce capsular redundancy and, when necessary, a reattachment of the avulsed labrum to the anteroinferior aspect of the glenoid.
A redundant capsular pouch was seen in all of the shoulders in this series. In addition, detachment of the anteroinferior aspect of the labrum was found in ten shoulders and an anterior fracture of the glenoid rim was seen in two shoulders. At an average of sixty-one months (range, twenty-four to 132 months), results were available for forty-nine shoulders (forty-six patients). Thirty shoulders (61 percent) had an excellent overall result, sixteen (33 percent) had a good result, one (2 percent) had a fair result, and two (4 percent) had a poor result. Forty-seven (96 percent) of the forty-nine shoulders remained stable at the time of follow-up. Two of the thirty-four shoulders that had been repaired through an anterior approach began to subluxate anteroinferiorly again. None of the fifteen shoulders that had been repaired through a posterior approach had recurrent instability. Full function, including the ability to perform strenuous manual tasks, was restored to forty-five shoulders (92 percent). A return to sports was possible after thirty-one (86 percent) of the thirty-six procedures done in athletes; however, a return to the premorbid level of participation was possible after only twenty-five (69 percent) of the thirty-six procedures.
The results in this series demonstrate the efficacy and the durability of the results of the inferior capsular shift procedure for the treatment of shoulders with multidirectional instability. The procedure directly addresses the major pathological feature - a redundant joint capsule. Similar results were seen with either an anterior or a posterior approach, and we continue to approach shoulders with multidirectional instability on the side of greatest instability. A postoperative brace was reserved for patients in whom a posterior approach had been used or in whom an anterior approach had involved extensive posterior capsular dissection (ten of the thirty-four shoulders treated with the anterior approach).
During arthroscopy of the shoulder, the ability to pass the arthroscope easily between the humeral head and the glenoid at the level of the anterior band of the inferior glenohumeral ligament is considered a positive drive-through sign. The drive-through sign has been considered diagnostic of shoulder instability and has been associated with shoulder laxity and with SLAP lesions. The goal of this study was to examine the prevalence of the drive-through sign in patients undergoing shoulder arthroscopy and to determine its relationship to shoulder instability, shoulder laxity, and to SLAP lesions.
Case series.
We prospectively studied 339 patients undergoing arthroscopy of the shoulder for a variety of diagnosis from 1992 to 1998. The drive-through sign was performed with the patients in a lateral decubitus position and under general anesthesia. The drive-through sign was correlated with preoperative physical findings, intraoperative laxity testing, and with intra-articular pathology at the time of arthroscopy.
The arthroscopic evaluation showed that drive-through sign was positive in 234 (69%) shoulders. For the diagnosis of instability, the drive-through sign had a sensitivity of 92%, a specificity of 37. 6%, a positive predictive value of 29.9%, a negative predictive value of 94.2%, and an overall accuracy of 49%. There was an association between the drive-through sign and increasing shoulder laxity, but not with SLAP lesions.
This study shows that a positive drive-through sign is not specific for shoulder instability but is associated with shoulder laxity. This arthroscopic sign should be incorporated with other factors when considering the diagnosis of instability.
This investigation presents the results of arthroscopic repair of bidirectional (inferior with either an anterior or a posterior component) glenohumeral instability in 54 patients with 2-year minimum follow-up. The study group consisted of 43 males and 11 females. The average age at the time of operation was 32 years (range, 15-55 years); the average interval from operation to final evaluation was 34 months (range, 26-63 months). The American Shoulder and Elbow Surgeons' Shoulder Index and the Constant, Rowe, and University of California at Los Angeles scores were recorded preoperatively and at final evaluation. Preoperatively, no patients rated good to excellent overall (according to the Rowe Scale), whereas at final follow-up 91% (49 of 54 patients) rated good to excellent. The American Shoulder and Elbow Surgeons' Shoulder Index improved to 94 from 45.5 (P =.001). The absolute Constant score improved to 92 from 57 (P =.001). The Rowe score improved to 92 from 20.3 (P =.001). The University of California at Los Angeles total score improved to 32.7 from 18.6 (P =.001). Average passive external rotation at 90 degrees of abduction measured 89.5 degrees. Forty patients returned to sports, but 10 (25%) of these patients participated at a lower level. For each of 4 patients, the index operation was considered a failure because of persistent instability; 1 patient underwent a second operative procedure. Thermal capsulorraphy (with a Holmium laser) of the glenohumeral ligaments was used to supplement suture repair, but in no shoulder was thermal capsulorraphy used as the only treatment. The etiology of bidirectional glenohumeral instability is complex, and operative correction of multiple intraarticular lesions was necessary.
Wound healing is a natural and well-orchestrated biologic event. Indeed, the ability of wounds to heal is the foundation on which the practice of surgery is predicated. The successful surgeon maintains a delicate alliance with nature, balancing the magnitude of the surgical insult against the capacity of the tissue for repair. Thermal injury is one of the most traumatic insults a tissue can sustain and the high degree of cell death and matrix alteration associated with thermal burns have been shown to result in a protracted healing time. Thus, the use of thermal energy as a stimulant for tissue shrinkage must be tempered with an appreciation of the biologic events that accompany this phenomenon. Furthermore, it must be realized that the initial degree of capsular shrinkage observed following the application of thermal energy may have little bearing on the long-term biologic and biomechanical status of the joint capsule. Therefore, the desire to see a redundant capsule shrink and become taut at surgery should be weighed very carefully against the level of damage imparted to the tissue to achieve this result. The simple initiation of the healing response may be sufficient to rehabilitate an incompetent structure via the creation of new cellular tissue. While the ultimate application(s) of thermal modification of connective tissues has yet to be completely defined, its ultimate role may be best suited to that of a low level stimulant for inducing a biologic repair response rather than a highly aggressive mechanism for primary tissue shrinkage.
The purpose of this study was to evaluate the rate of recurrence and the prevalence of complications related to the use of thermal energy for the treatment of glenohumeral instability.
A survey was conducted of all members of the American Shoulder and Elbow Surgeons, the Arthroscopy Association of North America, and the American Orthopaedic Society for Sports Medicine. The survey focused on the rate of recurrence, the number of axillary nerve injuries, and the prevalence of capsular insufficiency seen in revision surgery after thermal capsulorrhaphy of the shoulder.
Three hundred and seventy-nine surgeons responded to the survey. Of 236,015 shoulder procedures performed over the last five years, 14,277 (6%) involved the use of thermal energy (1,077 involved laser energy; 9,013, monopolar radiofrequency; and 4,187, bipolar radiofrequency) for the treatment of glenohumeral instability. The rates of recurrent instability after laser, monopolar radiofrequency, and bipolar radiofrequency capsulorrhaphy were 8.4%, 8.3%, and 7.1%, respectively. Of the patients with recurrent instability, 363 (twenty-one treated with laser energy, 220 treated with monopolar radiofrequency, and 122 treated with bipolar radiofrequency) required revision surgery. In this group of patients with revision surgery, seven (33%) of the twenty-one treated primarily with laser energy, thirty-nine (18%) of the 220 treated primarily with monopolar radiofrequency, and twenty-five (20%) of the 122 treated primarily with bipolar radiofrequency exhibited signs of capsular attenuation at the time of the revision. A total of 196 patients (1.4%) (three treated with laser energy; 133, with monopolar radiofrequency; and sixty, with bipolar radiofrequency) had a postoperative axillary neuropathy; 93% of the 196 had a sensory deficit only. Of these patients, 95% recovered completely, with the sensory deficits lasting an average of 2.3 months and the combined deficits, an average of four months.
The use of thermal energy for the treatment of shoulder instability has promising short-term results. The rates of recurrent instability are low. However, when recurrent instability occurs, capsular insufficiency may be present. Axillary nerve injury was reported in 1.4% of the patients, in most of whom it resolved spontaneously.
Redundancy of the anteromedial capsule of the shoulder may persist despite proper tensioning of the capsule and repair of a Bankart lesion during an anteroinferior capsular shift procedure.
A barrel-stitch suture technique incorporated into a capsular shift procedure is effective in achieving satisfactory shoulder stability.
Uncontrolled retrospective review.
A barrel-stitch technique was used for patients identified as having anteromedial capsular redundancy during a capsular shift procedure for anteroinferior instability.
The incidence of anteromedial capsular redundancy and labral deficiency was 49% (38 of 78). Patients with anteromedial capsular redundancy had a significantly greater number of dislocations before surgery (16.1 +/- 21.3 versus 7.4 +/- 7.4) and a greater duration of symptoms (79.8 +/- 84.2 versus 31.6 +/- 32.2 months). The mean postoperative Rowe score of patients with anteromedial capsular redundancy was 88.7 +/- 14.8, with 92% having excellent or good results, compared with 88.9 +/- 14.8 in the remaining patients and 93% excellent or good results.
Anteromedial capsular redundancy is associated with longer preoperative duration of symptoms and more dislocations, but effective treatment can be achieved with a capsular shift procedure augmented with medial capsular imbrication with a barrel stitch.
Thermal shrinkage of capsular tissue has recently been proposed as a means to address the capsular redundancy associated with shoulder instability. Although this procedure has become very popular, minimal peer-reviewed literature is available to justify its widespread use.
To prospectively evaluate the efficacy of arthroscopic electrothermal capsulorrhaphy for the treatment of shoulder instability.
This nonrandomized prospective study evaluated the indications and results of thermal capsulorrhaphy in 84 shoulders with an average follow-up of 38 months.
Patients were divided into three clinical subgroups: traumatic anterior dislocation (acute or recurrent), recurrent anterior anterior/inferior subluxation without prior dislocation, and multidirectional instability. Patients underwent arthroscopic thermal capsulorrhaphy after initial assessment, radiographs, and failure of a minimum of 3 months of nonoperative rehabilitation.
Outcome measures included pain, recurrent instability, return to work/sports, and the American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment score. Overall results were excellent in 33 participants (39%), satisfactory in 20 (24%), and unsatisfactory in 31 (37%).
The high rate of unsatisfactory overall results (37%), documented with longer follow-up, is of great concern. The authors conclude that enthusiasm for thermal capsulorrhaphy should be tempered until further studies document its efficacy.
This article presents an arthroscopic inferior capsular shift technique. In this technique, the same type of inferior capsular shift as with the open standard Neer procedure can be performed. After standard diagnostic shoulder arthroscopy, a bone trough is made along the capsular attachment to the humeral head using an abrader. An inverted L-shaped incision is performed in the anterior capsule. A suture is passed through the apex of this triangular flap, which is then pulled up and tied over the upper edge of the subscapularis, thus reducing the size of the wide anterior capsule. No hardware implants are used, and the procedure is not technically complicated. The surgery required fewer steps than open repair. The advantages of this technique are the preservation of the subscapularis, faster rehabilitation, and earlier return to normal activities, including sports. It also causes less postoperative range of motion limitation, while offering the same amount of capsular shift as the traditional open repair.
Anterior instability of the shoulder is classically treated with a capsulolabral repair, but in cases of capsular redundancy, shortening or shifting of the capsule is added. This study compared glenohumeral translations in intact shoulders after rotational stretching of the capsule and after progressive increasing of anterior-inferior capsular shifts. Seven cadaveric shoulders were mounted on a custom biomechanical testing apparatus. Rotational range of motion and glenohumeral translations were measured. To create laxity, the shoulders were rotationally stretched an additional 30% from the intact rotational range of motion about the axis of the humerus in external and internal rotation. Anterior-inferior capsular shifts of 5 and 10 mm were performed. Rotational stretching of the shoulder capsule created anterior laxity. A 5 mm capsular shift was ineffective, but a 10 mm shift restored anterior and total anteroposterior translation to the intact condition.
We evaluated the functional results of treatment with the selective capsular shift technique in patients with recurrent post-traumatic anterior-inferior glenohumeral instability.
The study included 16 patients (15 males, 1 female; mean age 30 years; range 25 to 38 years) who underwent selective capsular shift operation for recurrent post-traumatic anterior-inferior glenohumeral instability. Dislocations occurred following severe (n=14) or mild (n=2) trauma. Preoperatively, the mean number of dislocations was 14 (range 4 to 45) and magnetic resonance imaging showed a Bankart lesion in all the patients and a Hill-Sachs lesion in 20%. The patients were evaluated according to the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Rowe's scoring for Bankart repair. Preoperative and postoperative anteroposterior and axillary x-rays were obtained from all the patients. Range of motion was measured with a goniometer and manual muscle strength tests were performed. The mean follow-up was 41 months (range 21 to 74 months). Statistical analysis was made using the t-test.
The mean preoperative and postoperative ASES scores differed significantly (63.2 vs 95.8; p<0.05). The mean Rowe score was 92.5 (range 70 to 100). Strength of the infraspinatus, supraspinatus, and subscapularis muscles increased significantly (p<0.05). The results were excellent in 12 patients (75%), good in two patients (12.5%), and fair in two patients. Fifteen patients (93.8%) expressed satisfaction with the operation and results.
Addition of the selective capsular shift technique to the Bankart repair procedure improves stability and preserves the range of motion of the glenohumeral joint in patients with anterior-inferior glenohumeral instability accompanied by a Bankart lesion and capsular injury or laxity.
Numerous surgical techniques have been developed to treat glenohumeral instability. Anterior tightening procedures have been associated with secondary glenohumeral osteoarthritis, unlike the anterior-inferior capsular shift procedure, which has been widely advocated as a more anatomical repair. The objective of the present study was to quantify glenohumeral joint translations, articular contact, and resultant forces in cadaveric specimens in order to compare the effects of unidirectional anterior tightening with those of the anterior-inferior capsular shift.
Six normal fresh-frozen cadaveric shoulders were tested on a custom rig with use of a coordinate-measuring machine to obtain kinematic measurements and a six-axis load transducer to measure resultant external joint forces. Shoulders were tested in the scapular plane in three configurations (normal anatomical, anterior tightening, and anterior-inferior capsular shift) and in three humeral rotations (neutral, internal, and external). Glenohumeral articular surface geometry was quantified with use of stereophotogrammetry for kinematic and contact analyses. Resultant joint forces were computed on the basis of digitized coordinates of tendon insertions and origins.
Compared with the controls (maximum elevation, 167 degrees 8 degrees ), the anteriorly tightened specimens demonstrated loss of external rotation, significantly restricted maximum elevation (135 degrees 16 degrees , p = 0.002), posterior-inferior humeral head subluxation, and significantly greater posteriorly directed resultant forces at higher elevations (p < 0.05). In contrast, compared with the controls, the specimens that had been treated with the anterior-inferior capsular shift demonstrated a similar maximum elevation (159 degrees +/- 11 degrees , p = 0.8) without any apparent loss of external rotation and with reduced humeral translation.
Anterior tightening adversely affects joint mechanics by decreasing joint stability, limiting both external rotation and arm elevation, and requiring greater posterior joint forces to attain maximum elevation. The anterior-inferior capsular shift improves joint stability while preserving external rotation with no significant loss of maximum elevation.
Rotator interval tear is one of the lesions identified in patients with glenohumeral instability. We present our technique for arthroscopic interval capsule repair. After having performed Bankart reconstruction, we pull the anterosuperior cannula back some millimeters and introduce a Penetrator suture retriever forceps (Arthrex, Naples, FL) through the upper interval capsule into the joint. Then we also remove some millimeters of the anterior cannula and introduce a suture passer (Spectrum; Linvatec, Largo, FL) loaded with a monofilament suture through the lower interval capsule. The suture is pushed into the joint and, using the Penetrator suture retriever forceps, we retrieve it out of the joint. This suture is replaced if desired by a permanent braided suture. Next, a suture passer (Arthrex) advances the end of the suture from the anterosuperior portal into the joint. The suture is retrieved out of the joint from the anterior cannula with a crochet hook. We tie the suture down the anterior cannula to close the anterior capsule. Because we use cannulas, we can use a sliding knot. The degree of tightening can be observed directly under arthroscopic view but the knot is outside of the capsule. We believe that this method is easy, effective, and reproducible.
The purpose of this study was to objectively compare volume reduction after arthroscopic plication and open lateral capsular shift.
Experimental cadaver study.
Fifteen fresh-frozen human cadaver shoulders were assigned to 1 of 2 groups: arthroscopic plication (n = 7) or open lateral capsular shift (n = 8). Initial capsular volume was measured by repeated injection of a viscous fatty acid sulfate solution and recorded for each specimen. Repeated measurements were taken after the procedure to determine volume reduction.
Both procedures resulted in reduction of capsular volume. The arthroscopic plication resulted in a 22.8% volume reduction and the open lateral capsular shift resulted in a 49.9% volume reduction. Comparison of the 2 procedures revealed significant volume reduction after open lateral capsular shift compared with arthroscopic plication (P = .00001). Repeated measurements confirmed that the injection technique was valid and reproducible.
The lateral capsular shift resulted in significantly greater volume reduction compared with arthroscopic plication. Based on these results, we recommend an open lateral-based capsular shift for patients with multidirectional instability in which a larger capsular shift is required. However, additional plication sutures may allow for an even further reduction in volume. The amount of volume reduction required to eliminate instability still remains unknown for patients with shoulder instability caused by capsular laxity.
Level IV Case Series, in vitro anatomic comparison of 2 surgical procedures.
We performed arthroscopic treatment of traumatic anterior and anteroinferior shoulder instability combining three procedures--labrum repair, reduction of capsular volume and suture of the rotator cuff interval--with the aim of analysing the results with regard to stability and function. Between January 1999 and December 2003, 27 patients underwent arthroscopic treatment for labrum repair with metal anchors, reduction of capsular volume through thermal capsulorrhaphy and suture of rotator cuff interval. These patients were evaluated in the pre- and postoperative period using the UCLA and Rowe scales and in the postoperative period using the ASES scale. During a mean follow-up period of 32.4 months (range 22-74 months) all shoulders remained stable. Using the UCLA scale, there was improvement from the preoperative period, with a mean score of 24.7, to the postoperative period, with a mean of 32.81. Improvement was also shown by the Rowe scale, with a mean score of 39.81 in the preoperative period and 90.74 in the postoperative period. On the ASES scale the mean score was 92.22. All shoulders remained stable and there was marked functional improvement in the patients who were treated. These results are comparable to those obtained with open surgery, observing similar patient selection criteria.
The purpose of this study was to compare the percentage of glenohumeral intracapsular volume reduction after open inferior capsular shift and arthroscopic thermal capsulorrhaphy. Twelve matched, fresh-frozen cadaveric shoulders were used for the study. Intraarticular glenohumeral volume measurements were obtained by injecting a viscous fatty acid sulfate solution into the joint. In the 6 right shoulders, a standard anterior-inferior capsular shift was performed, and in the 6 matching left shoulders, an arthroscopic thermal capsular shrinkage was performed. After the procedures, the capsular volumes were re-measured. The open inferior shift procedure resulted in a mean decrease in glenohumeral volume of 50.2% (range, 43%-56%). Arthroscopic thermal capsulorrhaphy decreased shoulder intraarticular volume by a mean of 29.7% (range, 26%-36%). Both the open capsular shift and arthroscopic thermal shrinkage procedures produced well-documented volumetric reductions in the shoulder capsules. The open shift reduced intraarticular shoulder volume significantly more than arthroscopic thermal capsular shrinkage.
Multidirectional instability of the shoulder can be a difficult diagnostic and therapeutic dilemma for orthopaedic surgeons. First described by Neer and Foster, the mainstay of treatment is usually conservative, with most patients doing very well with nonoperative management. In patients with recalcitrant symptoms, surgical treatment primarily has been aimed at addressing the pathologically increased capsular volume. Newer studies suggest that the pathology also includes abnormal labral morphology and perhaps inadequate neuromuscular control. The arthroscopic treatment of multidirectional instability has come to have comparable results to open techniques when the multifactorial nature of the disease is recognized and the multiple techniques are used in combination to fully treat all pathology. Thermal capsulorrhaphy cannot be recommended at this time, except perhaps as an adjunct to other capsular plication or capsulorrhaphy techniques. The advantages of a less invasive procedure make arthroscopic capsular plication attractive, but it is associated with increased technical difficulty and a steep learning curve. Further studies are needed to distinguish a clear advantage of one over the other. Regardless of the technique used, the key to success is addressing the capsular laxity and redundancy to restore anatomic capsuloligamentous tension without overconstraining the shoulder.
We report the early and midterm results of the "purse-string" technique, a simple, new arthroscopic technique for stabilization of anteroinferior instability of the glenohumeral joint that addresses both the Bankart lesion and capsular stretching.
The patients comprised 36 individuals (37 shoulders), with a mean age of 26 years, who had recurrent anteroinferior post-traumatic instability as a result of a traumatic Bankart lesion. They had sustained a mean of 5 dislocations per shoulder (range, 1 to 11). The cohort included 5 professional and 6 semiprofessional athletes, all of whom were involved in collision or overhead sports. A purse-string suture anchor at the 4-o'clock position was used to ensure a purse-string effect in tightening the capsule in the inferior-superior plane and creation of anterior glenoid bumper. All of the patients were assessed by an independent investigator (T.M.) at a mean of 36 months (range, 27 to 87 months) after surgery.
Postoperatively, the mean Rowe score was 93 (range, 55 to 100), the mean Walch-Duplay score was 93 (range, 70 to 100), and the mean Constant score was 97 (range, 77 to 100). Of the patients, 97% returned to the same sport that they had played before injury. Furthermore, 66% of patients returned to their preinjury level of sports, and all of the professional athletes resumed full activities. One patient continued to have symptoms of instability, and one patient had a further dislocation after a new traumatic event.
The early and medium-term results obtained are very encouraging, with a rate of failure of only 5.4%, a high level of return to preinjury sporting activities (with 97% of patients returning to the same sport and 66% returning to their preinjury level of sports), and a high patient satisfaction rate (with excellent or good results in 94% of patients).
Level IV, therapeutic case series.
Few studies have documented the outcomes of thermal capsulorrhaphy for shoulder instability.
To examine prospective evaluate outcomes of the first 100 patients with glenohumeral instability treated with thermal capsulorrhaphy.
Case series; Level of evidence, 4.
Between 1997 and 1999, 85 of 100 patients treated with thermal capsulorrhaphy for glenohumeral instability were available for review at 2-year minimum follow-up (average, 4 years). Fifty-one patients suffered from anterior instability; 24 had an associated Bankart lesion. Ten patients demonstrated posterior instability; 1 had an associated reverse Bankart lesion. Seventeen patients had multidirectional instability; 8 had an associated Bankart lesion. Seven patients demonstrated anterior and posterior instability without an inferior component; 2 had an associated Bankart lesion. Failures were defined as shoulders requiring revision stabilization (14) or with recurrent instability (18), recalcitrant pain (3), or stiffness (2).
Forty-eight of 85 procedures were successful, and 37 of 85 failed. For patients with anterior instability plus a Bankart lesion, 7 of 24 (26%) had failed results. For those with anterior instability without a Bankart lesion, 10 of 27 (33%) had failed results. The failure rates for posterior, multidirectional instability, and anteroposterior were 60% (6/10), 59% (10/17), and 57% (4/7), respectively. Of the 48 successes, mean preoperative American Shoulder and Elbow Surgeons score improved from 71 to 96 postoperatively, and patient satisfaction was 9.1 on a 10-point scale.
Because of the high failure rates, we now augment thermal capsulorrhaphy with capsular plication and/or rotator interval closure in cases of posterior and multidirectional instability and have lengthened the initial immobilization period to improve outcomes. Failure rates for thermal capsulorrhaphy, even with labral repairs, are high especially for shoulders with multidirectional instability and posterior instability. When procedures were successful, however, patients were very satisfied with significant improvements in American Shoulder and Elbow Surgeons scores.
The anterior capsular shift is a well-established procedure for correction of capsular redundancy. Several different techniques have been developed to reduce capsular volume via a shift or capsulorrhaphy. The purpose of this study was to compare volume reduction objectively among 3 popular capsular shift techniques. Twenty-four fresh-frozen human cadaver shoulders were assigned to one of three groups: a lateral (humeral)-based T-capsular shift (group A), a medial (glenoid)-based T-capsular shift (group B), or a central vertical capsular shift (group C). Initial capsular volume was measured by repeated injection of a viscous fatty acid sulfate solution and recorded for each specimen. A predetermined capsular shift procedure was performed on each cadaver, and repeated measurements were made. All 3 procedures resulted in a significant reduction in capsular volume. The lateral (humeral)-based T-capsular shift resulted in the most reduction (48.9%). This reduction was statistically greater than for the glenoid-based shift (36.8% volume reduction) and approached statistical significance for the vertical shift (40.3% volume reduction, P =.12). Repeated measurements confirmed that the injection technique was valid and reproducible. The lateral (humeral)-based capsular shift results in the most volume reduction and should be considered the preferred procedure for patients with excessive capsular redundancy.
Capsular volume reduction is becoming a more popular procedure for treating the unstable shoulder. We present a novel technique of arthroscopic labral repair and capsular plication using a single suture anchor with two nonabsorbable braided sutures that repairs the involved labrum and capsule separately. It is a simple technique from the standpoint of simultaneous labral repair and capsular plication, making it easily reproducible and cost-effective.
The purpose of this study was to compare a new arthroscopic technique for capsular plication with the standard open inferior capsular shift for reducing volume in a multidirectional instability model.
Seven fresh-frozen cadaveric shoulders (mean age, 55 years) were dissected down to the capsule. A viscous liquid was injected into each shoulder joint and the volume measured. An arthroscopic multi-pleated anterior, posterior, and inferior capsular plication was performed through a single anterior and posterior portal by use of bioabsorbable suture anchors. The shoulder joint volume was again measured, and the sutures were then cut to restore the volume back to the original size. A humerus-based capsular release from 4 o'clock to 6 o'clock to the 8-o'clock position (right shoulder) was performed, the capsule shifted, and the volume recorded. A repeated-measures analysis of variance test was used with significance set at P = .05.
The mean baseline shoulder volume was 20 +/- 9 mL (range, 10 to 35 mL). The arthroscopic plication resulted in a mean decrease of 58% +/- 12%. The open inferior capsular shift resulted in a mean difference of 45% +/- 11%. There was a significant decrease in volume between the arthroscopic and open capsular shifts (P = .006, beta = .92).
This study proved our hypothesis that with this new arthroscopic technique for capsular plication, arthroscopic volume reduction can be achieved at least as well as with the standard open technique.
As the clinical results in the literature improve with improvements in arthroscopic techniques for treating shoulder instability, this arthroscopic method of repair could become invaluable in overcoming the challenge of capsular volume reduction when addressing multidirectional shoulder instability arthroscopically.
Complications of thermal capsulorrhaphy of the shoulder For reprints and permission queries, please visit SAGE's Web site
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Wong KL, Williams GR. Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am. 2001;83 Suppl 2(Pt 2): 151-155. For reprints and permission queries, please visit SAGE's Web site at http://www.sagepub.com/journalsPermissions.nav
Surgical repair for recurrent anterior dislocations. In: Shoulder Reconstruction. Philadelphia: WB Saunders
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Diagnosis of gleno-humeral instability
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Jerry SS, Jonathan CL, Josef PI, Gerald RW Jr. Diagnosis of gleno-humeral instability. In: Josef PI, Gerald RW Jr, eds. Disorders of the Shoulder. Philadelphia: Lippincott Williams & Wilkins; 2007:350-354.