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Arthroscopic Reinforced Capsular Shift of Anterior Shoulder Instability
Abstract
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.
... Actualmente en México, la técnica de plicatura con retensado por artroscopía no ha sido suficientemente explorada, no existen reportes para evaluar si es igual o mejor a la técnica abierta. 4,5 Si bien diversas técnicas a cielo abierto han demostrado ser eficaces en el restablecimiento de la estabilidad glenohumeral, siempre sus resultados han sido evaluados con índices de recurrencia y no como resultado funcional. Los pacientes con lesión de Bankart (desgarro del labrum) pueden presentar inestabilidad glenohumeral anterior, por lo que hay que realizar reparación de esta, vía artroscópica con la reinserción del labrum por medio de suturas fijadas con anclas en la glenoides, siendo la vía artroscópica una buena alternativa terapéutica, por la evolución postoperatoria y manejo de la rehabilitación. ...
Show the experience of the Orthopedics Service at Lic. Adolfo López Mateos Regional ISSSTE Hospital, in the management of anterior unidirectional shoulder instability with an arthroscopic technique consisting of reattaching the labrum in the glenoid with anchored sutures and capsular tightening with radiofrequency.
Twenty-six patients with anterior unidirectional shoulder instability who were operated-on between August 2006 and November 2008 were included. Twelve patients underwent capsular retightening with radiofrequency and in 14 patients the latter was combined with sutured anchors. The patients selected had a history of relapsing glenohumeral dislocations and subluxations with anterior instability, with or without associated Bankart lesions, and all of them were young.
The results were assessed basically with the functional UCLA scale and considering the occurrence of any instability-related event during the postoperative follow-up; from this perspective, there were no cases of recurrent instability. Two cases reported severe postoperative pain, and one had irritation of the sutures; 6 patients had residual limitation of combined lateral rotation and abduction movements, with a mean of 10 degrees compared with the sound contralateral limb. The most frequent incident was infiltration of solutions into the soft tissues due to the operative time.
Capsular retightening with radiofrequency, whether combined or not with other repair techniques, has proven highly satisfactory from the perspective of the glenohumeral stabilization for anterior unidirectional instability. The arthroscopic approach offers the known advantages of being less aggressive to the soft tissues and a shorter time to resume work activities when rehabilitation therapy and exercises are followed.
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.
Arthroscopic transglenoid suture of Bankart lesions was performed in 31 patients from 1988 to 1992. The diagnosis in all patients was recurrent traumatic anterior luxation, and a Bankart lesion was found in all cases. Mean time for clinical follow-up was 43 months (ranging from 25 to 76 months). A telephone review of all cases was obtained two years later. Five patients experienced postoperative wound problems posteriorly, where the sutures were tied over the fascia of the infraspinatus. One transient suprascapular nerve palsy was seen. There was a recurrence of complete dislocation in eight patients, while six patients had had repeated subluxations (total failure rate of 45.1%). Sixteen patients (51.6%) were assessed as having good to excellent results according to the Rowe scoring system. A slight loss of external rotation was found in six cases. Seventeen patients (54.8%) were able to return to their pre-injury level of athletic activity. Due to the high failure rate, we do not recommend arthroscopic transglenoid suture of Bankart lesions in patients with recurrent traumatic anterior dislocations.
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.
In thirty-six patients (forty shoulders) with involuntary inferior and multidirectional subluxation and dislocation, there had been failure of standard operations or uncertainty regarding diagnosis or treatment. Clinical evaluation of these patients stressed meticulous psychiatric appraisal, conservative treatment, and repeated examination of the shoulder. All patients were treated by an inferior capsular shift, a procedure in which a flap of the capsule reinforced by overlying tendon is shifted to reduce capsular and ligamentous redundancy on all three sides. This technique offers the advantage of correcting multidirectional instability through one incision without damage to the articular surface. One shoulder began subluxating again within seven months after operation, but there have been no other unsatisfactory results to date. Seventeen shoulders were followed for more than two years.
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.
The results of arthroscopic stabilization using multiple transglenoid sutures in 24 patients with posttraumatic recurrent anterior shoulder instability are presented with a minimum follow-up of 2 years. No serious complications were recorded. There were 2 recurrences. The remaining 22 patients had good or excellent results according to the modified Rowe score, with a median score of 89. The median value for loss of external rotation was 5 degrees. Seventeen patients were active in sports and 11 returned to the same sports at the same competitive level.
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.
Scoring systems for the shoulder conditions FIGURE 6. (A) The flap is shifted superiorly and laterally to lie on the prepared trough. (B) After the repair is complete; the knot is extracapsular and the capsule is shifted
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Romeo AA, Bach BR, O'Halloran KL. Scoring systems for the shoulder conditions. Am J Sports Med 1996;24:472-476. FIGURE 6. (A) The flap is shifted superiorly and laterally to lie on the prepared trough. (B) After the repair is complete; the knot is extracapsular and the capsule is shifted. 546 B. A. FLEEGA
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