Arthroscopic multi-pleated capsular plication compared with open inferior capsular shift for reduction of shoulder volume in a cadaveric model

Multidirectional instability of the shoulder: surgical techniques and clinical outcome

Multidirectional instability of the shoulder has a complex pathoanatomy. It is characterized by a redundant glenohumeral capsule and increased joint volume. Subtle clinical presentation, unclear trauma history and multifactorial etiology poseses a great challenge for orthopedic surgeons in terms of diagnosis. Generally accepted therapeutic approach is conservative and the majority of patients achieve good results with rehabilitation. In patients who are symptomatic despite appropriate rehabilitation, surgical intervention may be considered. Good results have been obtained with open inferior capsular surgery, which has historically been performed in these patients. In recent years, advanced arthroscopic techniques have taken place in this field, and similar results compared to open surgery have been obtained with the less-invasive arthroscopic capsular plication procedure.

Clinical Outcomes After Arthroscopic Pancapsular Shift for the Treatment of Multidirectional Glenohumeral Instability at a Mean Follow-up of 9 Years

BACKGROUND

Arthroscopic treatment of multidirectional instability (MDI) of the shoulder is being increasingly performed, but there is a paucity of studies with minimum 5-year follow-up.

PURPOSE

To report on survivorship and patient-reported outcomes (PROs) after arthroscopic pancapsulorraphy (APC) for MDI with a minimum 5-year follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Institutional review board approval was obtained before initiation of this retrospective review of prospectively collected data. Patients were included if they had a minimum of follow-up 5 years after APC for MDI. PROs included the 12-Item Short Form Health Survey Physical Component Summary; American Shoulder and Elbow Surgeons; Single Assessment Numeric Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; and patient satisfaction. Preoperative, short-term (1-2 years), and final follow-up PROs were compared. Recurrent instability, dislocation, and reoperation were collected, and survivorship analysis was performed.

RESULTS

A total of 49 shoulders in 44 patients (15 male, 29 female) treated between October 2005 and November 2015 were included in the study. MDI onset was atraumatic in 27 shoulders and traumatic in 22. Rotator interval closure was performed in 17 patients. Overall, 14 of 49 (29%) patients reported feelings of instability in the shoulder, of whom 5 (10.2%) underwent revision surgery at a mean of 1.5 years. Kaplan-Meier analysis demonstrated a survivorship rate of 88% at 5 years and 82% at 8 years, with failure defined as requiring revision surgery or postoperative feelings of instability with ASES score <65. Final outcome analysis was performed on 41 shoulders with a mean follow-up of 9.0 years (range, 5.1-14.6 years). All PROs demonstrated significant improvement from preoperative baseline (P < .05) and remained significantly improved at both short-term and long-term final follow-up. There was no difference in PROs based on \\ atraumatic versus traumatic onset, or patients treated with a rotator interval closure. There was a significant difference in PROs between patients who had continued instability.

CONCLUSION

APC for the treatment of MDI provided reasonable, durable long-term PROs that persisted from short-term follow-up. Although 29% of patients experienced feelings of instability at final follow-up, most of these patients still had high postoperative satisfaction and acceptable PROs.

Arthroscopic Capsular Plication for Multidirectional Shoulder Instability in Hypermobile Ehlers-Danlos Syndrome Patients

Patients with hypermobile Ehlers-Danlos syndrome commonly present with painful shoulder disorders mostly represented by a multidirectional instability and with often painless episode of atraumatic shoulder dislocation and/or subluxation. Because of the generalized soft tissue fragility, most of the surgical treatments of shoulder instability, as the Bankart repair or the Latarjet procedure becomes not effective, exposing a risk of failure. Then, capsular plication has to be considered in order to reduce the articular joint volume and to diminish the mobility of the joint. Two main benefits of this surgical procedure are that it doesn't modify the anatomy or damage the labrum or cartilage that is healthy. The purpose of this Technical Note is to present the arthroscopic capsular plication for the treatment of patient with hypermobile Ehlers-Danlos syndrome, which is associated with a multidirectional shoulder instability.

What Are the Effects of Capsular Plication on Translational Laxity of the Glenohumeral Joint: A Study in Cadaveric Shoulders

BACKGROUND

Surgical treatment for shoulder instability generally involves labral repair with a capsular plication or imbrication. Good results are reported in both open and arthroscopic procedures, but there is no consensus on the amount or location of capsular plication that is needed to achieve stability and anatomic anterior, posterior, and inferior translation of the joint.

QUESTIONS/PURPOSES

(1) What are the separate and combined effects of increasing plication magnitude and sequential additive plications in the anterior, posterior, and inferior locations of the joint capsule on glenohumeral joint translation in the anterior, posterior, and inferior directions? (2) What plication location and magnitude restores anterior, posterior, and inferior translation to a baseline level?

METHODS

Fourteen cadaveric shoulders were dissected down to the glenohumeral capsule and underwent instrumented biomechanical testing. Each shoulder was loaded with 22 N in anterior, posterior, and inferior directions at 60° abduction and neutral rotation and flexion and the resulting translation were recorded. Testing was done over baseline (native), stretched (mechanically stretched capsule to imitate a lax capsule), and 5-mm, 10-mm, and 15-mm plication conditions. Individually, for each of the 5-, 10-, and 15-mm increments, plications were done in a fixed sequential order starting with anterior plication at the 3 o'clock position (Sequence I), then adding posterior plication at the 9 o'clock position (Sequence II), and then adding inferior plication at the 6 o'clock position (Sequence III). Each individual sequence was tested by placing 44 N (10 pounds) of manual force on the humerus directed in an anterior, posterior, and inferior direction to simulate clinical load and shift testing. The effect of plication magnitude and sequence on translation was tested with generalized estimating equation models. Translational differences between conditions were tested with paired t-tests.

RESULTS

Translational laxity was highest with creation of the lax condition, as expected. Increasing plication magnitude had a significant effect on all three directions of translation. Plication location sequence had a significant effect on anterior and posterior translation. An interaction effect between plication magnitude and sequence was significant in anterior and posterior translation. Laxity in all directions was most restricted with 15-mm plication in anterior, posterior, and inferior locations. For anterior translational laxity, at 10-mm and 15-mm plication, there was a progressive decrease in translation magnitude (10-mm plication anterior only: 0.46 mm, plus posterior: 0.29 mm, plus inferior, -0.12 mm; and for 15-mm anterior only: -0.53 mm, plus posterior: -1.00 mm, plus inferior: -1.66 mm). For posterior translational laxity, 10-mm and 15-mm plication also showed progressive decrease in magnitude (10-mm plication anterior only: 0.46 mm, plus posterior: -0.25 mm, plus inferior: -1.94; and for 15-mm anterior only: 0.14 mm, plus posterior: -1.54 mm, plus inferior: -3.66). For inferior translational laxity, tightening was observed only with magnitude of plication (anterior only at 5 mm: 0.31 mm, at 10 mm: -1.39, at 15 mm: -3.61) but not with additional plication points (adding posterior and inferior sequences). To restore laxity closest to baseline, 10-mm AP/inferior plication best restored anterior translation, 15-mm anterior plication best restored posterior translation, and 5 mm posterior with or without inferior plication best restored inferior translation.

CONCLUSIONS

Our results suggest that (1) a 10-mm plication in the anterior and posterior or anterior, posterior, and inferior positions may restore anterior translation closest to baseline; (2) 10-mm anterior and posterior or 15-mm anterior plications may restore posterior translation closest to baseline; and (3) 5-mm anterior and posterior or anterior, posterior, and inferior plications may restore inferior translation closest to baseline. Future studies using arthroscopic techniques for plication or open techniques via a true surgical approach might further characterize the effect of plication on glenohumeral translation.

CLINICAL RELEVANCE

This study found that specific combinations of plication magnitude and location can be used to restore glenohumeral translation from a lax capsular state to a native state. This information can be used to guide surgical technique based on an individual patient's degree and direction of capsular laxity. In vivo testing of glenohumeral translation before and after capsular plication will be needed to validate these cadaveric results.

Arthroscopic Treatment of Hip Pain in Adolescent Patients With Borderline Dysplasia of the Hip: Minimum 2-Year Follow-Up

PURPOSE

To examine arthroscopic treatment of hip pain in patients with borderline hip dysplasia (lateral center edge angle [LCEA] between 20° and 25°).

METHODS

From 2008 to 2013, patients below 18 years of age who underwent arthroscopic hip surgery with an LCEA between 20° and 25° were retrospectively matched 1:1 to a control group without dysplasia (LCEA ≥25°) based on age, gender, femoroplasty, labral treatment, and capsular plication. Indications for surgery included failure to improve with nonoperative treatments and anti-inflammatory medications after 3 months. Patient-reported outcome data were collected using modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale.

RESULTS

From 2008 to 2013, 168 patients below the age of 18 underwent arthroscopic hip surgery. Twenty-one patients met inclusion criteria and were matched 1:1 to a control group. Follow-up was achieved for 17 patients in both groups (81%). Mean follow-up time, age, and LCEA were 2.19 years, 15.5 years, and 22.3° for the dysplastic group and 2.16 years, 16.0 years, and 31.2° for the control group, respectively. Preoperative patient-reported outcomes between groups were not statistically different. At the latest follow-up, both groups showed statistically significant improvement over baseline in modified Harris hip score, hip outcome score-activities of daily living subscale, hip outcome score-sports-specific subscale, nonarthritic athletic hip score, and visual analog scale (P < .001). Latest follow-up scores were not statistically different between groups.

CONCLUSIONS

This study shows favorable 2-year outcomes in adolescent patients with borderline dysplasia undergoing labral treatment and capsular plication. Outcomes in the borderline dysplastic patients were as good as those of a control group. Although adolescents with borderline dysplasia have traditionally been a challenging group of patients to treat, these results suggest that an arthroscopic approach that addresses both labral pathology and instability may be beneficial.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Arthroscopic Pancapsular Shift With Labral Repair for Multidirectional Instability of the Shoulder

Initial treatment of shoulder multidirectional instability (MDI) consists of nonoperative modalities of physical therapy and rehabilitation; if this fails, surgical treatment can become necessary. MDI of the shoulder can be challenging to manage in individuals who fail conservative management. Historically, surgical treatment for MDI has been open capsular plication; however, arthroscopic capsular plication has now become the standard of care, with outcomes similar to the open procedure. The purpose of this article and Video 1 is to describe our arthroscopic technique for pancapsular shift with labral repair.

Medial Posterior Capsular Plication Reduces Anterior Shoulder Instability Similar to Remplissage Without Restricting Motion in the Setting of an Engaging Hill-Sachs Defect

BACKGROUND

Numerous surgical options for the management of engaging Hill-Sachs lesions exist, of which remplissage has emerged as one of the most popular arthroscopic techniques. Remplissage is not without disadvantages, however, and has been demonstrated to potentially result in a loss of external rotation (ER) due to nonanatomic tethering of the infraspinatus tendon and a potential decrease in infraspinatus strength clinically.

PURPOSE

The efficacy of posterior medial capsular plication in addition to Bankart repair was examined as an arthroscopic management strategy for an engaging Hill-Sachs defect.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen human cadaveric shoulders were utilized for the study. After testing baseline translation and motion, 30% Hill-Sachs lesions were created in each specimen. Three experimental groups were assembled: (1) isolated Bankart repair (HSD), (2) Bankart repair with remplissage (RM), and (3) Bankart repair with posterior medial capsular plication (PL). Biomechanical testing was performed to determine anterior translation, range of motion, and Hill-Sachs engagement. Translation and motion measurements were normalized to the baseline laxity values for each specimen.

RESULTS

A significant reduction in anterior translation was noted at 60° of abduction and 60° of ER for both the PL and RM groups compared with the HSD group throughout most of the joint loads tested ( P < .05), but no significant differences were noted between the PL and RM groups at any load. The RM group had significantly less normalized ER at 60° of abduction compared with the HSD and PL groups ( P < .05). There were no differences in internal rotation between the groups. All 8 specimens in the HSD group engaged, while no specimens in the RM and PL groups engaged ( P < .001).

CONCLUSION

In a cadaveric model, medial posterior capsular plication as an adjunct to Bankart repair offers similar resistance to anterior translation and Hill-Sachs engagement as compared with remplissage in the setting of an engaging Hill-Sachs defect. Medial posterior capsular plication results in less restriction of ER compared with remplissage without any significant limitation of internal rotation.

CLINICAL RELEVANCE

Posterior medial capsular plication reduces translation and engagement similarly to remplissage, without any restriction in motion.

Arthroscopic plication for multidirectional instability: 50 patients with a minimum of 2 years of follow-up

BACKGROUND

Treatment of patients who have not improved after physiotherapy for multidirectional instability (MDI) remains challenging, with no agreed best practice. The purpose of this study was to ascertain whether arthroscopic plication is safe and effective for these patients.

METHODS

Fifty consecutive patients who had not improved after at least 6 months of specialized shoulder physiotherapy for symptomatic MDI and no labral lesion at arthroscopy underwent arthroscopic plication between 2006 and 2013. Outcome measures were preoperative and postoperative Oxford Instability Scores (OIS), recurrence of instability, return to work and sport, surgical complications, and patient satisfaction.

RESULTS

The study comprised 32 male and 18 female patients, with a mean age of 26 years (range, 16-46 years). Complete OISs were available in 43 of 50 patients, and 41 patients had good or excellent postoperative OIS. The mean OIS was 16.2 preoperatively compared with 42.5 postoperatively (P < .001). There was no difference in OIS improvement between male and female patients (P = .962) or in those aged younger than 25 years vs. older than 25 years (P = .789). Patients with Beighton scores of 4 to 9 showed smaller OIS improvement (P = .030) and were less likely to achieve excellent postoperative OISs (P = .010). There were 2 patients with recurrent instability. All patients successfully returned to work, and 45 of 50 patients returned to the same level of sport. Surgical complications were shoulder stiffness in 1 patient that resolved with physiotherapy and 1 superficial wound infection that was successfully treated with flucloxacillin. Forty-seven of 50 patients were satisfied.

CONCLUSION

Arthroscopic plication is a safe and effective treatment for MDI in patients without labral lesions who have not improved after 6 months of specialized shoulder physiotherapy.

Outcomes After Arthroscopic Pancapsular Capsulorrhaphy With Suture Anchors for the Treatment of Multidirectional Glenohumeral Instability in Athletes

BACKGROUND

Outcomes after arthroscopic pancapsular capsulorrhaphy (APC) with suture anchors for multidirectional instability (MDI) of the shoulder are not widely reported.

PURPOSE

To compare intraoperative findings and midterm outcomes of APC with suture anchors for MDI between female and male athletes and between a classic, atraumatic onset versus clinical onset of MDI after a traumatic event.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent APC with suture anchors for MDI and were at least 2 years out from surgery were included. Data were prospectively collected and retrospectively reviewed and included the onset of MDI, intraoperative pathoanatomic findings, level of sports participation, and patient satisfaction as well as the American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Short Form-12 Physical Component Summary (SF-12 PCS) scores. Information regarding shoulder instability and return to sport was collected, and Kaplan-Meier survivorship analysis was performed.

RESULTS

Forty-one patients (45 shoulders; 25 male, 20 female), consecutively treated between October 2006 and January 2013, were included. The onset of MDI was atraumatic in 22 shoulders and traumatic in 23 shoulders. At surgery, 29 of 45 (64.4%) had labral detachment. Seven shoulders (16.7%) experienced instability episodes postoperatively, and 3 of these underwent revision surgery. The mean follow-up was 3.3 years (range, 2.0-6.6 years). All subjective outcome scores improved significantly from preoperative levels (P < .005). At final follow-up, the mean ASES score was 92.0, and 76.7% (23/30) indicated that they had returned to sports participation equal to or slightly below their preinjury level. Kaplan-Meier analysis showed a survivorship rate of 87% at 3 years. Male patients were 2.3 times more likely to have a traumatic onset of instability (68% vs 30%, respectively; P = .017) and were 2.1 times more likely to have concomitant lesions (84% vs 40%, respectively; P = .004) than female patients. Furthermore, male patients demonstrated a higher mean postoperative ASES score than female patients (97.0 ± 4.7 vs 85.5 ± 16.4, respectively; P = .023). Female patients were 6.9 times more likely to undergo an additional rotator interval closure (RIC) procedure (58% vs 4.7%, respectively; P < .001) and to experience postoperative subluxations (40% vs 22%, respectively; P = .035) than male patients. A traumatic onset of MDI was associated with a higher mean postoperative ASES score (96.4 ± 6.9 vs 87.0 ± 15.7, respectively; P = .048), higher median satisfaction score (10 vs 9, respectively; P = .029), and higher return-to-sport rate (83% vs 44%, respectively; P = .030) than an atraumatic onset.

CONCLUSION

APC with suture anchors can be an effective and safe treatment for patients with MDI. Labral tears were commonly found, even in patients with a classic, atraumatic onset. Male patients and patients with a traumatic onset of MDI had more favorable outcomes. Female patients may be more challenging to treat as they were more likely to undergo an additional RIC procedure and experience postoperative subluxations.

Evaluation and treatment of failed shoulder instability procedures

Management of the unstable shoulder after a failed stabilization procedure can be difficult and challenging. Detailed understanding of the native shoulder anatomy, including its static and dynamic restraints, is necessary for determining the patient’s primary pathology. In addition, evaluation of the patient’s history, physical exam, and imaging is important for identifying the cause for failure after the initial procedure. Common mistakes include under-appreciation of bony defects, failure to recognize capsular laxity, technical errors, and missed associated pathology. Many potential treatment options exist for revision surgery, including open or arthroscopic Bankart repair, bony augmentation procedures, and management of Hill Sachs defects. The aim of this narrative review is to discuss in-depth the common risk factors for post-surgical failure, components for appropriate evaluation, and the different surgical options available for revision stabilization.

Level of evidence Level V.

Open inferior capsular shift for multidirectional shoulder instability in adolescents with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome

BACKGROUND

The objective of this study was to assess the outcome of open inferior capsular shift for multidirectional shoulder instability in patients with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome.

METHODS

Data were obtained for 18 open inferior capsular shift surgeries in 15 adolescent patients with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome with a mean follow-up of 7.5 years. End points were subjective clinical outcome (pain, stability, satisfaction, return to sport), objective clinical outcome (recurrence, complications), and functional outcome scores (American Shoulder and Elbow Surgeons, 11-item version of the Disabilities of Arm, Shoulder and Hand).

RESULTS

Thirteen patients (87%) reported improved pain and stability and were satisfied with the procedure. Nine patients (64%) were able to return to sports. One patient (7%) was dissatisfied with continuous pain and recurrent instability and considered a surgical failure. Seven patients (47%) reported no further episodes of instability. The mean American Shoulder and Elbow Surgeons score at a mean of 7.5 years of follow-up was 88 ± 10 points, and the mean score for the 11-item version of the Disabilities of Arm, Shoulder and Hand was 14 ± 14 points.

DISCUSSION

The management of multidirectional shoulder instability in adolescent patients with generalized ligamentous hyperlaxity or Ehlers-Danlos syndrome is challenging. Open inferior capsular shift results in improvement in subjective and objective shoulder function and stability in adolescent patients with ligamentous hyperlaxity or Ehlers-Danlos who have failed nonoperative treatment. We found no effect of the recalled number of prior dislocations, laterality, and type of hyperlaxity on subjective and objective clinical outcomes.

LEVEL OF EVIDENCE

Level IV; Case Series; Treatment Study.

History of surgical intervention of anterior shoulder instability

BACKGROUND

Anterior glenohumeral instability most commonly affects younger patients and has shown high recurrence rates with nonoperative management. The treatment of anterior glenohumeral instability has undergone significant evolution over the 20th and 21 centuries.

METHODS

This article presents a retrospective comprehensive review of the history of different operative techniques for shoulder stabilization.

RESULTS

Bankart first described an anatomic suture repair of the inferior glenohumeral ligament and anteroinferior labrum in 1923. Multiple surgeons have since described anatomic and nonanatomic repairs, and many of the early principles of shoulder stabilization have remained even as the techniques have changed. Some methods, such as the Magnusson-Stack procedure, Putti-Platt procedure, arthroscopic stapling, and transosseous suture fixation, have been almost completely abandoned. Other strategies, such as the Bankart repair, capsular shift, and remplissage, have persisted for decades and have been adapted for arthroscopic use.

DISCUSSION

The future of anterior shoulder stabilization will continue to evolve with even newer practices, such as the arthroscopic Latarjet transfer. Further research and clinical experience will dictate which future innovations are ultimately embraced.

The volume of the human knee joint

INTRODUCTION

Despite its clinical relevance, particularly in septic knee surgery, the volume of the human knee joint has not been established to date. Therefore, the objective of this study was to determine knee joint volume and whether or not it is dependent on sex or body height.

METHODS

Sixty-one consecutive patients (joints) who were due to undergo endoprosthetic joint replacement were enrolled in this prospective study. During the operation, the joint volume was determined by injecting saline solution until a pressure of 200 mmHg was achieved in the joint.

RESULTS

The average volume of all knee joints was 131 ± 53 (40-290) ml. The volume was not found to be dependent on sex, but it was dependent on the patients' height (R = 0.312, p = 0.014). This enabled an estimation of the joint volume according to V = 1.6 height - 135.

CONCLUSIONS

The considerable inter-individual variance of the knee joint volume would suggest that it should be determined or at least estimated according to body height if the joint volume has consequences for the diagnostics or therapy of knee disorders.

Inferior suture anchor placement during arthroscopic Bankart repair: influence of portal placement and curved drill guide

BACKGROUND

During arthroscopic Bankart repair, inferior anchor placement is critical to a successful outcome. Low anterior anchors may be placed with a standard straight guide via midglenoid portal, with a straight guide with trans-subscapularis placement, or with curved guide systems. Purpose/

HYPOTHESIS

To evaluate glenoid suture anchor trajectory, position, and biomechanical performance as a function of portal location and insertion technique. It is hypothesized that a trans-subscapularis portal or curved guide will improve anchor position, decrease risk of opposite cortex breach, and confer improved biomechanical properties.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty cadaveric shoulders were randomized to 1 of 3 groups: straight guide, midglenoid portal (MG); straight guide, trans-subscapularis portal (TS); and curved guide, midglenoid portal (CG). Three BioRaptor PK 2.3-mm anchors were inserted arthroscopically, with an anchor placed at 3, 5, and 7 o'clock. Specimens were dissected with any anchor perforation of the opposite cortex noted. An "en face" image was used to evaluate actual anchor position on a clockface scale. Each suture anchor underwent cyclic loading (10-60 N, 250 cycles), followed by a load-to-failure test (12.5 mm/s). Fisher exact test and mixed effects regression modeling were used to compare outcomes among groups.

RESULTS

Anchor placement deviated from the desired position by 9.9° ± 11.4° in MG specimens, 11.1° ± 13.8° in TS, and 13.1° ± 14.5° in CG. After dissection, opposite cortex perforation at 5 o'clock occurred in 50% of MG anchors, 0% of TS, and 40% of CG. Of the 90 anchors tested, 17 (19%) failed during cyclic loading, with a similar failure rate across groups (P = .816). The maximum load was significantly higher for the 3-o'clock anchors when compared with the 5-o'clock anchors, regardless of portal or guide (P = .021). For the 5-o'clock position, there were significantly fewer "out" anchors in the TS group versus the CG or MG group (P = .038). There was no statistically significant difference in maximum load among groups at 5 o'clock.

CONCLUSION

Accuracy in suture anchor placement during arthroscopic Bankart repair can vary depending on both portal used and desired position of anchor. The results of the current study indicate that there was no difference in ultimate load to failure among anchors inserted via a midglenoid straight guide, midglenoid curved guide, or percutaneous trans-subscapularis approach. However, midglenoid portal anchors drilled with a straight or curved guide and placed at the 5-o'clock position had significant increased risk of opposite cortex perforation compared with trans-subscapularis percutaneous insertion, with no apparent biomechanical detriment.

CLINICAL RELEVANCE

The findings from this study will facilitate improved understanding of risks and benefits of several techniques for arthroscopic shoulder instability treatment with regard to suture anchor fixation.

Arthroscopic stabilization for voluntary shoulder instability

BACKGROUND

Voluntary shoulder instability is characterized by a patient's ability to sublux their shoulder using selective muscle contraction and relaxation. High failure rates exist with open shoulder stabilization in this group of patients. The purpose of this study was to report the outcomes for patients with voluntary instability treated arthroscopically.

METHODS

All patients with voluntary instability from 2006 to 2008 treated with arthroscopic stabilization were included. All patients had documentation of preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) questionnaire score, visual analogue scale of pain, simple shoulder test, and range of motion. Subjective satisfaction and return to sport was also determined.

RESULTS

Ten patients were identified for inclusion in the study. The average age of the 5 male and 5 female patients was 16.2 ± 2.33 years. Average clinical follow-up period was 31 ± 6.5 months. Visual analogue scale scores improved from 5.33 ± 3.50 preoperatively to 1.44 ± 2.0 postoperatively, ASES scores improved from 52.2 ± 18.7 to 85.9 ± 14.9 and simple shoulder test improved from 8.17 ± 3.19 to 11.4 ± 1.01. All of the functional evaluation scores improved postoperatively (P < 0.05). There was no case of postoperative dislocation or subluxation, all reported excellent subjective outcome, and all those who played sports returned to their previous level.

CONCLUSIONS

Good and excellent outcomes can be obtained with arthroscopic stabilization for patients with voluntary instability. Improved results from previous reports may be related to improved patient selection, surgical technique, and postoperative rehabilitation. Although long-term follow-up and comparative studies are necessary, arthroscopic stabilization seems to be an acceptable treatment option for patients who fail nonoperative treatment.

LEVEL OF EVIDENCE

Level IV, case series, retrospective review.

An arthroscopic pleated capsular shift for recurrent anterior dislocation of the shoulder

PURPOSE

This study examined the clinical results of an arthroscopic simple pleated capsular shift to treat severe recurrent anterior dislocation of the shoulder.

METHODS

Twenty-four patients with anterior labroligamentous periosteal sleeve avulsion or advanced lesions who underwent an arthroscopic simple pleated capsular shift were included in this study. To create an arthroscopic simple pleated capsular shift, redundant capsules, including glenohumeral ligaments, were brought at least 1 cm lateral and 1 cm inferior and shifted to the prepared glenoid. Four sutures were made at the 5, 4, 3, and 1-2 o'clock positions with four anchors. Clinical results were evaluated using a visual analog scale (VAS), ROWE scores, active motion, and return to activity. Statistical analyses were carried out using paired t tests.

RESULTS

Three out of 24 patients had complaints. Two patients with recurrent instability underwent a repeat surgery, while the other patient complained of a stiff shoulder. There was a significant improvement in the VAS and ROWE scores post-operatively versus pre-operatively (p < 0.001, p < 0.001, respectively), but no significant differences in active motion except for external rotation, which decreased post-operatively (p = 0.02).

CONCLUSIONS

In patients with severe recurrent anterior dislocation, simple pleated capsular shift provided a reliable result. Four capsular shift sutures, 1 cm lateral and 1 cm inferior from the glenoid, were sufficient to reduce shoulder joint volume and restore stability. The arthroscopic capsular shift could be an alternative method in the case of no available labral lesion for repair.

LEVEL OF EVIDENCE

Case series, Therapeutic, Level IV.

Evaluation and management of posterior shoulder instability

CONTEXT

Posterior shoulder instability is a commonly misdiagnosed disorder in many competitive athletes.

TYPE OF STUDY

Clinical review.

EVIDENCE ACQUISITION

Relevant studies on posterior shoulder instability from 1950 to 2010 in PubMed and Cochrane databases were reviewed.

RESULTS

A total of 107 studies were reviewed.

CONCLUSION

Patients who have undergone at least 6 months of physical therapy and still experience instability symptoms should be considered for surgical stabilization directed at their underlying pathology.

Arthroscopic inferior capsular shift: long-term follow-up

BACKGROUND

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.

PURPOSE

To assess the results of a new arthroscopic reinforced inferior capsular shift technique based on Neer and Foster's open inferior capsular shift.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

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.

RESULTS

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.

CONCLUSION

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 pancapsular plication for multidirectional shoulder instability in overhead athletes

Treating shoulder multidirectional instability with an open stabilization procedure has been reported to have good results. However, few studies exist of arthroscopic plication, especially in overhead athletes. The purpose of this study was to evaluate the clinical outcomes of arthroscopic pancapsular plication for multidirectional instability in overhead athletes.Twenty-three athletes with symptomatic multidirectional instability were treated with arthroscopic pancapsular plication and evaluated at a mean follow-up of 36.3 months (range, 24-61 months). Mean patient age was 23.3 years (range, 19-33 years). Functional outcomes were evaluated with the American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder score, and Rowe instability score. The degree of pain and range of motion were also recorded. All postoperative functional scores were rated good to excellent, with an average ASES score of 88.4 (range, 82-95), average Constant shoulder score of 88.1 (range, 81-100), and average Rowe instability score of 86.7 (range, 80-100). Five patients returned to the same level of competitive sports, and 18 returned to a limited level. All patients were satisfied with the stability postoperatively. No significant change was observed in postoperative range of motion, but patients who returned to a limited level of sports had lower functional scores and more pain than did those who fully returned to sports.Arthroscopic pancapsular plication for treating multidirectional instability in overhead athletes can provide good stability. However, the low rate of return to a full level of overhead sports is a problem. Further evaluation of the benefits of this procedure for overhead athletes with symptomatic multidirectional instability is needed.

The effect of a Hill-Sachs defect on glenohumeral translations, in situ capsular forces, and bony contact forces

BACKGROUND

Hill-Sachs defects have been associated with failed repairs for anterior shoulder instability. However, the biomechanical consequences of these defects are not well understood because of the complicated interaction between the passive soft tissue and bony stabilizers.

HYPOTHESIS

The creation of a 25% Hill-Sachs defect would not significantly alter the glenohumeral translations but would increase the in situ forces in the glenohumeral capsule as well as the glenohumeral bony contact forces.

STUDY DESIGN

Controlled laboratory study.

METHODS

A robotic/universal force-moment sensor (UFS) testing system was used to apply joint compression (22 N) and an anterior or posterior load (44 N) to cadaveric shoulders (n = 9) with the skin and deltoid removed (intact) at 3 glenohumeral joint positions (abduction/external rotation): 0°/0°, 30°/30°, and 60°/60° (corresponds to 90°/90° of shoulder abduction/external rotation). A 25% bony defect on the posterolateral humeral head (defect) was then created in the most common position of anterior shoulder dislocation (90°/90°), and the loading protocol was repeated. A nonparametric repeated-measures Friedman test with a Wilcoxon signed-rank post hoc test was performed to compare translations, in situ forces in the capsule, and bony contact forces between each state (P < .05).

RESULTS

At 0°/0°, anterior translation significantly increased from 15.3 ± 8.2 mm to 16.6 ± 9.0 mm (P < .05) in response to an anterior load. At 30°/30°, anterior and posterior translations, respectively, significantly increased in response to both anterior (intact: 13.6 ± 7.1 mm vs defect: 14.2 ± 7 mm; P < .05) and posterior loads (intact: 15.7 ± 5.8 mm vs defect: 17.7 ± 5.1 mm; P < .05). In situ force in the capsule during anterior loading was increased in the defect state at both 60°/60° (intact: 38.9 ± 14.4 N vs defect: 43.2 ± 15.9 N; P < .05) and 30°/30° (intact: 39.6 ± 13.8 N vs defect: 45.6 ± 9.3 N; P < .05). The medial bony contact forces were also increased in the defect state at 30°/30° (intact: 25.0 ± 13.8 N vs defect: 28.9 ± 13.2 N; P < .05) during anterior loading.

CONCLUSION

We believe that the stabilizing function of the intact capsule was the primary contributor to the finding of only small increases of anterior translation, capsule forces, and bony contact forces observed with a 25% Hill-Sachs defect in response to an anterior load.

CLINICAL RELEVANCE

These findings imply that a 25% Hill-Sachs defect in isolation may not be responsible for recurrent instability if the function of the capsule is restored to the intact state and that the presence of the Hill-Sachs defect may be a marker for significant concomitant injury to the anterior glenoid rim. However, the small changes in these parameters may have long-term implications for the development of osteoarthritis.

Management of multidirectional instability of the shoulder

Multidirectional shoulder instability is defined as symptomatic instability in two or more directions. Instability occurs when static and dynamic shoulder stabilizers become incompetent due to congenital or acquired means. Nonspecific activity-related pain and decreased athletic performance are common presenting complaints. Clinical suspicion for instability is essential for timely diagnosis. Several examination techniques can be used to identify increased glenohumeral translation. It is critical to distinguish increased laxity from instability. Initial management begins with therapeutic rehabilitation. If surgical management is required, capsular plication has been used successfully. Advanced arthroscopic techniques offer several advantages over traditional open approaches and may have similar outcomes. The role of rotator interval capsular plication is controversial, but it may be used to augment capsular plication in patients with specific patterns of instability. Despite encouraging results, outcomes remain inferior to those associated with traumatic unidirectional instability.

The rationale for an arthroscopic approach to shoulder stabilization

The gold standard of treatment for glenohumeral instability has traditionally been viewed as open shoulder stabilization. With the increased awareness of complex instability patterns and the ability to preoperatively detect concomitant pathology with advanced imaging modalities, an evidence-based shift to an all-arthroscopic approach to shoulder stabilization surgery is occurring. Current data suggest that patients who meet eligibility criteria for arthroscopic stabilization (those without significant bony lesions or significant deformity) can expect equivalent rates of recurrence, better functional outcomes, and less morbidity. Modern arthroscopic techniques using suture anchors and capsular plication have resulted in a significant improvement over previous reports in the orthopaedic literature. An argument is put forth on the benefits of an all-arthroscopic approach to shoulder stabilization in athletes and nonathletes alike based on a review of the current orthopaedic literature comparing the evolved arthroscopic technique with more traditional open methods.

Failure of operative treatment for glenohumeral instability: etiology and management

Failure of primary shoulder stabilization procedures is often related to uncorrected anatomic pathology. Orthopaedic surgeons must recognize excessive capsular laxity or large glenohumeral bone defects preoperatively to avoid recurrence of instability. When history, physical examination, and radiographic evaluation are used in conjunction, patients at risk for failure can be identified. The instability severity index score permits precise identification of patients at risk. When treating patients in whom prior surgical intervention has failed, the success of revision procedures correlates to the surgeon's ability to identify the essential pathology and use lesion-specific treatment strategies. Revision procedures remain technically demanding. Keen preoperative and intraoperative judgment is required to avoid additional recurrence of instability after revision procedures, particularly because results deteriorate with each successive operation. Glenoid or humeral defects with greater than 25% bone loss compromise stability provided through the mechanism of concavity compression. These defects must be specifically addressed to avoid recurrence of instability. We prefer anatomic reconstruction techniques combined with capsulolabral repair and, if bone defects are present, anatomic reconstruction with osteochondral allograft.

Sequential volume reduction with capsular plications: relationship between cumulative size of plications and volumetric reduction for multidirectional instability of the shoulder

PURPOSE

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.

STUDY DESIGN

Controlled laboratory study.

METHODS

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.

RESULTS

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/

CLINICAL RELEVANCE

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.

Arthroscopic glenoid osteochondral allograft reconstruction without subscapularis takedown: technique and literature review

Failure to address glenoid deficiency/osteochondral defects can lead to persistent shoulder instability despite a surgical stabilization procedure. In patients with significant glenoid bone loss, osteoarticular allograft transplantation has the potential benefit of restoring normal glenohumeral anatomy. It may also reduce the risk of recurrent instability and permit near-normal postoperative range of motion while avoiding the complications of nonanatomic reconstruction techniques. Numerous open methods of anatomic glenoid reconstruction have been described, including the use of iliac crest autograft, distal tibia allograft, and glenoid allograft. Our purpose is to review the literature regarding the surgical treatment of glenoid bone deficiency. We also describe a novel technique of arthroscopic anteroinferior glenoid reconstruction using glenoid osteochondral allograft without subscapularis takedown. The potential risks and benefits of our technique are also discussed.

Arthroscopic management of multidirectional instability

The most critical step in successful treatment of shoulder instability does not lie in surgical technique, but in accurate assessment of factors contributing to instability. Multidirectional instability (MDI) is initially treated with rehabilitation. The primary goal of rehabilitation is strengthening of the dynamic stabilizers, including the rotator cuff and scapular stabilizers. There are several surgical techniques described to manage MDI, ranging from the classic Neer inferior capsular shift to a variety of arthroscopic procedures. This article focuses on the arthroscopic management of MDI.

Arthroscopic treatment of multidirectional glenohumeral instability in young overhead athletes

Purpose:

This prospective case series evaluates the outcome, and the return to sports of young overhead athletes with a persistent, symptomatic multidirectional instability (MDI) with hyperlaxity type Gerber B5 treated with an arthroscopic anteroposteroinferior capsular plication and rotator interval closure.

Methods:

9 young overhead athletes (10 shoulders) with the rare diagnosis of MDI (Gerber B5) and an indication for operative treatment, after a failed physiotherapy program were physically examined 3, 6 and 12 months postoperatively by a physical examination, and got a final phone interview after median 39 months.

Results:

At the final follow-up all patients were satisfied; Rowe Score showed 7 “excellent” and “good” results; Constant Score was “excellent” and “good” in 6, and “fair” in 1 patient. 7/9 returned to their previous sports, 3/9 at a reduced level.

Conclusion:

Symptomatic MDI requires an individual indication for surgical treatment after a primary conservative treatment. The described arthroscopic technique stabilizes glenohumeral joint. A return to overhead sports is possible but often at a reduced level; returning to high-performance sports cannot be recommended because of the high risk of reinstability.

[Multidirectional shoulder instability. Nonoperative and operative treatment strategies]

Multidirectional shoulder instability (MDI) is characterized by symptomatic instability in at least two directions, often with a global hyperlaxity. The etiology is mostly atraumatic, with an acquired or congenital enlarged capsular volume or redundancy. Muscular imbalances and pathologic patterns of muscle recruitment and motion are also common findings. Traumatic onset of MDI is rare, although capsulolabral lesions can be found during surgery. Therapy aims at a normalization of muscle balance/weakness and motion patterns. If conservative treatment fails, arthroscopic capsular plication techniques, in combination with repair of labral and interval lesions, can accomplish results similar to those of classic open techniques but with reduced morbidity and invasiveness.