Arthroscopic Treatment of Multi-Directional Instability of the Shoulder Raymond Y. Whitehead, M.D.
Shoulder Stability Dependent upon a variety of anatomic factors Static restraints of capsulolabral complex Negative intra-articular pressure Dynamic compression from intact cuff
Shoulder Instability Laxity - objectively describes the extent to which the humeral can be translated on the glenoid Instability - is an abnormal increase in glenohumeral translation that causes symptoms (subluxation or dislocation)
Classsification of Instability - “TUBS” Traumatic Unidirectional Bankart lesion Surgery to achieve stability
Classsification of Instability - “AMBRII” Atraumatic Multidirectional Bilateral excessive laxity Rehabilitation usually therapeutic Inferior capsular shift if surgery required Rotator Interval closure
Continuum of Shoulder Instability Now viewed as a spectrum Atraumatic Multidirectional Microinstability from repetitive microtrauma Bidirectional Traumatic unidirectional
Pathophysiology The anatomic lesion found in MDI is a large, patulous inferior capsular pouch that extends both anteriorly and posteriorly in varying degrees, creating a global increase in capsular volume. Redundant inferior glenohumeral ligament complex with a resultant increase in capsular volume.
Pathophysiology The inferior capsule resists inferior translation increasingly with progressive arm abduction to 90 degrees Rotator interval widening with attenuated tissue, appearing as a broad cleft. The rotator interval resists inferior translation with the arm at the side
Pathophysiology Effect of rotator cuff Dynamic stabilization Effect of concavity compression Scapular stabilizers Synovial fluid adhesion-cohesion stabilization forces Negative intra-articular pressure
Pathophysiology Self-perpetuating viscous cycle Asymptomatic patient with laxity Pain or fatigue secondary to repetitive use or traumatic event Painful protected shoulder results in muscle weakness and diminished neuromuscular coordination Exxacerbation of instability More pain and subsequent weakness secondary to disuse
Etiology Congenital bilateral generalized ligamentous laxity Acquired Repetitive stress Overhead athletes Manual laborers Traumatic Congenital laxity exacerbated by traumatic subluxation/dislocation
Clinical Features of MDI Symptomatic with activity Objective evidence of glenohumeral subluxation or dislocation
History Most common complaint is pain Pain: ADL’s Overhead activity Repetitive motion Sensation of shoulder looseness Often no frank history of dislocation
History Voluntary vs. Involuntary Neurologic symptoms transient numbness, tingling, and weakness provocative positions and activities
Physical Exam Inspection Atrophy Deltoid contour Supraspinatus contour
Physical Exam Generalized ligamentous laxity ROM - passive and active elbow hyperextension MCP joint hyperextension genu recurvatum patellar subluxation thumb-to-forearm ROM - passive and active
Physical Exam Motor strength Neurologic testing Palpation AC jt Acromion Provocative testing impingement O’Brien, Speed, etc.
Physical Exam - Instability Testing Sulcus test adducted arm assesses the rotator interval 90 degrees abduction assesses the inferior capsule Load-and-shift vary both abduction and external rotation Anterior stress (lachman of shoulder) Posterior stress Apprehension
Radiographic Exam True AP Axillary Supraspinatus Outlet MRI Little to no role in pure MDI Useful to assess concomitant labral, intra-articular , and rotator cuff pathology
Differential Diagnsosis MDI Traumatic instability Combined Impingement Cervical radiculopathy Thoracic outlet Other labral lesion
Nonoperative Treatment Patient education Physical therapy Rotator cuff strengthening Scapular stabilization Neuromuscular coordination NSAIDS & analgesics prn Burkhead and Rockwood 88% successful treatment of MDI with rehab
Surgical Candidates Compliant patients Failed rehab X 6 months Continued symptoms
NO Surgery Voluntary dislocators Emotionally unstable Behaviorally immature teenagers
Surgical Options Open inferior capsular shift Glenoid osteotomy Thermal capsular shrinkage Arthroscopy
Caution A patient with generalized laxity who experiences an inciting traumatic event may experience clinical failure of operative treatment if capsular laxity not addressed at the time of Bankart / surgical reconstruction. Speer et al. JBJS, 76A, 1994 Capsular injury associated with dislocation and creation of Bankart lesion
Open Capsular Shift Altchek, JBJS, 1991 95% excellent with glenoid based shift
Open Capsular Shift Neer & Foster, JBJS, 1980 97% excellent with humeral based shift
Open Capsular Shift Jobe -ACLR
Open Capsular Shift Bigliani, AJSM, 1994 recurrence rate of 1.5% The inferior capsular shift, either glenoid or humeral based, is the standard procedure for surgical management of MDI.
Advantages of Arthroscopy Improved cosmesis Complete glenohumeral inspection Address all labral pathology Treat intra-articular lesions Maximal preservation of motion Diminshed post-op pain Less blood loss
Arthroscopic Options Staple Capsulloraphy Transglenoid Suture capsulloraphy Thermal capsulloraphy RF vs. Laser Rotator interval plication Arthroscopic Capsular plication
Caspari multiple suture transglenoid capsular shift McIntyre, et al, “The Arthroscopic Treatment of MDI: 2-year Results of a Multiple Suture Technique,” Arthroscopy, 13(4), 1997, 418-425. Caspari multiple suture transglenoid capsular shift 19 patients with symptomatic MDI 14 injured in athletics 4 frank dislocations Surgical findings 7 with anterior & posterior bankart lesions 2 with anterior bankart lesion alone 2 with labral fraying 9 with excessive capsular laxity
McIntyre, et al, Arthroscopy, 13(4), 1997, 418-425. Arthroscopic Technique Capsular incision adjacent to labrum if no bankart Anterior sutures placed transglenoid
McIntyre, et al, Arthroscopy, 13(4), 1997, 418-425. Posterior capsular release from glenoid 5 mm tag inferiorly at inferior glenoid b/w incisions Posterior sutures placed transclavicular or through spine of scapula
McIntyre, et al, Arthroscopy, 13(4), 1997, 418-425. 1 repeat anterior subluxation Treated with repeat arthroscopic procedure 13 excellent, 5 good, & 1 fair result All athletes returned to previous level of athletic participation Minimal loss of ROM Conclusion: The described technique proved safe and effective in treating MDI and enabling athletes to return to their previous level of function.
Thermal Capsulorraphy Capsular shrinkage secondary to heat delivered by either a RF probe or laser Heat disrupts crosslinks in Type I collagen causing contraction of the triple helix Greater response in tissue with higher collagen densities (IGHL, MGHL)
Thermal Capsulorraphy RF energy provides shortened scaffold for fibroblasts to lay down new collagen Maturation process may take 4-6 weeks Therefore, immobilization required to prevent activities which may stretch scaffold In vivo results of elongated tissue after shrinkage without immobilization
Thermal Capsulorraphy Little clinical data Long term effects of thermal modification of tissue are unknown Recent literature somewhat pessimistic and detrimental More info required before more widespread use recommended
33 patients with MDI min. 6 mo. Follow-up 1-bankart & 3-SLAP JP Bradley, “ Thermal Capsulorraphy for MDI,” Instr. Course Lect., 2001. 33 patients with MDI min. 6 mo. Follow-up 1-bankart & 3-SLAP 10 unsatisfactory (29%) Because of high failure rate, increased immobilization from 2 to 6 weeks Anecdotally improved results for the next 60 patients enrolled in the study
30 patients with unipolar RF shrinkage with combined RI plication Savoie & Field, “Thermal vs. Suture Treatment of Symptomatic Capsular Laxity,” Clin Sports Med, 2000. 30 patients with unipolar RF shrinkage with combined RI plication 2 dislocations rehab begin after 3 weeks in sling 28 of 30 rated satisfactory (93%) 2 failures (7%) one with early return to sport other did well for 18 months then with recurrent subluxations
26 patients with arthroscopic transglenoid capsular shift Savoie & Field, “Thermal vs. Suture Treatment of Symptomatic Capsular Laxity,” Clin Sports Med, 2000. 26 patients with arthroscopic transglenoid capsular shift 15 dislocations 3 patients with recurrent instability 1 - high school pitcher with loss of velocity 1 - college basketball
32 patients with YAG-laser capsular shift Savoie & Field, “Thermal vs. Suture Treatment of Symptomatic Capsular Laxity,” Clin Sports Med, 2000. 32 patients with YAG-laser capsular shift 2 patients unable to return to collegiate level baseball 1 - recurrent instability 1 - RTC tear
Savoie & Field, “Thermal vs Savoie & Field, “Thermal vs. Suture Treatment of Symptomatic Capsular Laxity,” Clin Sports Med, 2000. Conclusion: Clinical results of thermal capsulorraphy are comparable to arthroscopic shift and laser shift Results suggest thermal capsulorraphy is an effective treatment alternative for patients with MDI
Thermal Capsulorraphy Unknowns Long term effect on capsular tissues Effect of temperature on proprioception and nerve endings Time for capsular collagen reorganization In patients with congenital laxity does collagen become more lax over time. No long term outcomes
failed 6 months rehab, activity modification, and NSAIDS Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001, 236-243. 47 patients with true MDI excluded work comp & instability in 2 directions failed 6 months rehab, activity modification, and NSAIDS 20 recurrent dislocators 27 recurrent subluxators
Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001, 236-243. Operative Technique Goal: repair ligament or labral detachments anatomically, then recreate adequate capsular tension Labrum was not shifted but repaired anatomically Ligament and capsular advancement onto labrum or glenoid rim as dictated by individual anatomy (capsular plication) Typically 5 to 15 mm of lateral and superior ligament advancement performed Anterior, inferior, and posterior capsule addressed Rotator interval plication
Post-op management 15 degree abduction sling x 6 weeks Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001, 236-243. Post-op management 15 degree abduction sling x 6 weeks begin AROM at 2 weeks FF limited to 90 ER limited to 40 unrestricted AROM and strengthening at 6 weeks
Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001, 236-243. Operative Findings Essential finding was large capsular volume and excessive humeral head translation anteriorly, inferiorly, and posteriorly Labral repair alone not sufficient to restore stability alone All patients required capsular tightening
Post-operative Scores and Ratings Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001, 236-243. Post-operative Scores and Ratings ASES, Constant, Rowe, & UCLA All significantly improved final Rowe score of 93.7 45 of 47 rated good to excellent satisfaction with UCLA
4 of 28 not return to sports participation 1 - persistent instability Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001, 236-243. 4 of 28 not return to sports participation 1 - persistent instability 1 - pain with throwing 2 - loss of strength One failure at 18 months with recurrent subluxation revision surgery showed unhealed superior portion of bankart
Gartsman, et al, “Arthroscopic Treatment of MDI: 2-5 year Follow-up,” Arthroscopy, 17(3), 2001, 236-243. Conclusion: Patients with MDI have multiple lesions within the shoulder and the surgeon must individualize the operative treatment. Repair of rotator interval was an essential element to the operative treatment Arthroscopic anatomic repair of all labral attachments and suture capsulorraphy to restore capsular tension produced successful results.
Traumatic anterior inferior instability 34 patients Tauro, “Arthroscopic Inferior Capsular Split and Advancement for Anterior and Inferior Shoulder Instability: Technique and Results at 2-5 year Follow-up,” Arthroscopy, 16(5), 2000, 451-456. Traumatic anterior inferior instability 34 patients 22 – anterior inferior dislocations 10 – chronic recurrent anterior inferior subluxations 2 – MDI 5 – acute first time dislocators Surgical findings 29 – Bankart lesions 5 – labral abrasions with markedly lax ant/inf capsules
Tauro, Arthroscopy, 16(5), 2000, 451-456. Inferior Capsular Split
Tauro, Arthroscopy, 16(5), 2000, 451-456. Post-op Shoulder immobilizer x 4 weeks Immediate ER to 0 degrees Immediate Abd to 45 degrees Immobilizer d/c @ 4wks Begin ER to 30 and full Abd along with light resisted IR & ER 8 wks – progress to full ROM and strengthening
Tauro, Arthroscopy, 16(5), 2000, 451-456. Results No recurrences in acute dislocators 1 chronic subluxator with recurrent subluxations 3 chronic dislocators with recurrent dislocations Caused by trauma 2 of 5 failures in transglenoid recurred 2 of 29 in failures suture anchor group Minimal loss of ROM Good rate of return to prev activity
Tauro, Arthroscopy, 16(5), 2000, 451-456. Conclusion Do not detach capsule if no bankart present (capsular plication only) Addition of inferior capsular split and advancement to bankart procedure addresses plastic capsular elongation as a result of dislocation and therefore may improve results of arthroscopic treatment of anterior inferior instability.
No documented dislocations (one with hx of reduction in ER) Wolf & Eakin, “Arthroscopic Capsular Plication for Posterior Shoulder Instability,” Arthroscopy, 14(2), 1998, 153-163. 14 patients Pain with overhead activity and with provocative motions (flex, IR, Add) No documented dislocations (one with hx of reduction in ER) Positive “jerk” test post stress with flex, IR, Add 6 mo. Pre-op rehab
Wolf & Eakin, Arthroscopy, 14(2), 1998, 153-163. EUA – unilateral posterior instability Arthroscopic Technique Posterior portal 1-2 cm more inferior and lateral than usual Capsular abrasion Plication with Linvatec crescent suture hook & No. 1 PDS Arthroscopic findings Posterior capsular laxity in all patients 8 with labrals lesions (reverse bankart)
Wolf & Eakin, Arthroscopy, 14(2), 1998, 153-163. 11 returned to preinjury level 4 collegiate & high school athletes 11 full return of strength 1 recurrent instability 5 mo. Post op 1 work comp case Conclusion – Capsular plication is a promising technique for addressing capsular laxity in patients with recurrent posterior shoulder instability
Nebelung et al, “A New Technique of Arthroscopic Capsular Shift in Anterior Shoulder Instability,” Arthroscopy, 17(4), 2001, 426-429. Designed to address redundant anterior & inferior capsuloligamentous tissues as a result of repeated ant/inf. Dislocations Vertical mattress suture through capsular tissue to imbricate capsule onto labrum Secured with an anchor
Treatment of MDI with Suture Plication J.C. Esch Metcalf Course 2001 Surgical Goals: Eliminate capsular redundancy Tighten loose structures “Widen” glenoid Reduce joint volume Balance loose ligaments
Treatment of MDI with Suture Plication Tighten: posterior band of IGHL anterior band of IGHL advance MGHL superiorly to close the rotator interval Capsular abrasion prior to plication
Treatment of MDI with Suture Plication Snyder, AANA 1999 23 patients with no bankarts 87% satisfied; 18 exc/good Rowe scores Wolf, AANA 1999 20 MDI; 13 trauma & 9 atraumatic 75% good/exc 5 patient with recurrent instability
Contraindications to Arthroscopy Nelson & Arciero, AJSM, 28(4) 2000 patients with excessive capsular laxity, bilateral atraumatic shoulder instability, and signs of excessive ligamentous laxity are not ideal candidates for arthroscopic stabilization patients with no bankart lesion and a large, patulous inferior pouch are poor candidates for arthroscopic stabilization. Patients participating in collision sports.
Contraindications to Arthroscopy Romeo, AANA, Nov., 2000 Contact athletes History of multiple recurrences Anterior instability with NO bankart lesion “Poor quality” tissue Pathologic ligamentous laxity
Nelson & Arciero, AJSM, 28(4) 2000 Arthroscopic management of MDI is still in its developmental stage. There are few studies available for review, and the published reports have small numbers and short follow-up. A further problem is the diverse presentation and pathoanatomy observed in patients with MDI
What is the Problem? Studies on MDI include patients with a variety of pathologic lesions “Spectrum of instability” Address capsular laxity with traumatic lesions Difficult to interpret results Different expectations for different patients Pain in overhead worker Elite overhead athlete?
What To Do? Overhead athlete (thrower, tennis, swimming, gymnastics) with subtle instability and pain. Moderate anterior and inferior laxity and subluxation with no hx of dislocation. Failure to respond to rehab. No labral pathology. +/- mild internal cuff abrasion
What To Do?
What To Do? Most difficult Does thermal have a role? Capsular Plication Rotator Interval Plication
Arthroscopic Managment of MDI Summary Address all labral palthology Address associated capsular laxity Capsular plication Capsular shift +/- Thermal Rotator interval plication Critical review and continued evaluation of results
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