Treatment of multidirectionalshoulder instability in the athlete

Multidirectional instability in the athlete refers to symptomatic laxity of the shoulder in more than one direction.This is in contrast to unidirectional instability, which involves subluxation or dislocation in only one direction. The diagnosis and treatment of this disorder can be challenging owing to the unusual demands athletes place on their shoulders to be effective in their sport. The laxity required for overhand throwing, gymnastics, swimming, volleyball and tennis — while increased compared with that required for activities of daily living or with that of the opposite shoulder — must be symptomatic to be pathologic. Formerly, it was thought that generalized ligamentous laxity was a requirement for multidirectional instability, but now it is realized many athletes have multidirectional instability in the setting of otherwise normal ligamentous laxity. Nonoperative treatment is frequently successful in these athletes. When conservative management is unsuccessful, the capsular shift procedure has demonstrated good results in allowing these athletes to return to their sport. Arthroscopic and thermal capsulorrhaphy also offer other options for surgical treatment of this problem and will be briefly discussed.     

Inferior capsular shift operation for multidirectional instability of the shoulder in players of contact sports

OBJECTIVES: To assess the results of inferior capsular shift for multidirectional instability of the shoulder in athletes. METHODS: Multidirectional instability was surgically corrected in 53 shoulders in 47 athletes who engaged in contact sports. A history of major trauma was found in eight patients, the others having had minor episodes. Before surgery, all patients had complex combinations of instabilities. The surgical approach was selected according to the predominant direction of instability. RESULTS: Anterior inferior capsular shift was carried out in 37 shoulders, and anterior dislocation recurred in three. In one of these, it was anterior alone, one was anterior and inferior, and one was unstable in all three directions. After posterior inferior capsular shift in 16 shoulders, one dislocation occurred anteriorly and one posteriorly. With the anterior approach, four athletes could not return to sport. Two patients treated with the posterior approach could not return to sport. Of these six failures, five patients had had bilateral repairs. Successful repair based on the criteria of the American Shoulder and Elbow Association was achieved in 92% of anterior repairs and 81% of posterior repairs. Successful return to sport was noted in 82% of patients with anterior repairs, 75% with posterior repairs, and 17% with bilateral repairs. Overall, there were five subsequent dislocations, three in the anterior repair group (8%), and two in the posterior repair group (12%). CONCLUSIONS: Inferior capsular shift can successfully correct multidirectional instability in most players of contact sports, but the results in bilateral cases are poor.     

Prospective evaluation of thermal capsulorrhaphy for shoulder instability: indications and results, two- to five-year follow-up

BACKGROUND: 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. PURPOSE: To prospectively evaluate the efficacy of arthroscopic electrothermal capsulorrhaphy for the treatment of shoulder instability. STUDY DESIGN: This nonrandomized prospective study evaluated the indications and results of thermal capsulorrhaphy in 84 shoulders with an average follow-up of 38 months. METHODS: 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. RESULTS: 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%). CONCLUSIONS: 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.     

Thermal versus suture treatment of symptomatic capsular laxity

This article reviews the clinical results of unipolar thermal capsular shrinkage in 30 patients and compares that group to similar groups previously managed by laser-assisted capsulorrhaphy or by an arthroscopic capsular shift procedure. Patients were evaluated with respect to incidence of recurrent instability, the need for reoperation, and the ability to return to previous levels of activity or sports participation. Patients were rated as satisfactory or unsatisfactory based on criteria established by Neer. The results of this study suggest that thermal capsulorrhaphy with rotator interval plication is an effective treatment alternative for multidirectional instability, with results comparable to those previously reported with open and arthroscopic procedures.     

Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy

Twenty-five athletes (26 shoulders) who underwent an inferior capsular shift procedure for multidirectional glenohumeral instability based on isolated capsular and ligamentous redundancy were evaluated at a median of 54 months (range, 25 to 113) after the operation. Twenty-one athletes (84%) returned to their preinjury activity level at a median of 5 months after surgery. Of 21 athletes involved in sports using overhead motions, 16 (76%) returned to their previous sport after the operation, and 12 (57%) were still active in this sport at the preinjury level at follow-up. According to the Rowe score, 23 shoulders (88%) were excellent or good. The University of California at Los Angeles score for 24 shoulders (92%) was excellent or good. The operations on two shoulders (8%) failed. One patient had a spontaneous redislocation, and one had recurrent subluxations. Nine contralateral shoulders had a history of significant instability; four of these had undergone Bankart repair. We concluded that athletes who have multidirectional instability based on isolated capsular and ligamentous redundancy can be successfully treated by an inferior capsular shift preserving the subscapularis tendon insertion. We found a high rate of return to demanding upper extremity sports in our patients, range of motion was restored in the majority of shoulders, and the failure rate after a median of 54 months was acceptable.     

Laser capsulorrhaphy for multidirectional instability of the shoulder. An outcomes study and proposed classification system

BACKGROUND: Clinical data on the efficacy of laser capsulorrhaphy for the treatment of multidirectional instability of the shoulder are limited. HYPOTHESIS: The diagnosis of multidirectional instability includes a spectrum of pathologic symptoms that warrants subclassification; laser capsulorrhaphy alone is not uniformly effective for all subtypes. STUDY DESIGN: Retrospective review of prospectively collected data. METHODS: Twenty-five shoulders in 21 patients were treated with laser capsulorrhaphy for multidirectional instability. Functional outcomes at a mean duration of 32 months' follow-up (range, 24 to 48 months) were recorded. RESULTS: Instability recurred in 60% of patients with congenital multidirectional instability, 17% of patients with acquired multidirectional instability, and 33% of patients with posttraumatic multidirectional instability (overall recurrence rate, 40%). Generalized ligamentous laxity was a risk factor for recurrence. Patient satisfaction rates were 40%, 83%, and 22% for the congenital, acquired, and posttraumatic subgroups. Reasons for dissatisfaction included recurrent instability, persistent pain, and inability to return to athletic activity at desired capacity. The overall mean postoperative Simple Shoulder Test score was 84%. The mean postoperative numeric rating score for pain was 3.3 (10-point scale). CONCLUSIONS: Laser capsulorrhaphy may be effective for patients with acquired multidirectional instability secondary to repetitive microtrauma but is less predictable in the other subgroups.     

Revision surgery for failed thermal capsulorrhaphy

BACKGROUND: With the failure of thermal capsulorrhaphy for shoulder instability, there have been concerns with capsular thinning and capsular necrosis affecting revision surgery. PURPOSE: To report the findings at revision surgery for failed thermal capsulorrhaphy and to evaluate the technical effects on subsequent revision capsular plication. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fourteen patients underwent arthroscopic evaluation and open reconstruction for a failed thermal capsulorrhaphy. The cause of the failure, the quality of the capsule, and the ability to suture the capsule were recorded. The patients were evaluated at follow-up for failure, which was defined as recurrent subluxations or dislocations. RESULTS: The origin of the instability was traumatic (n = 6) or atraumatic (n = 8). At revision surgery in the traumatic group, 4 patients sustained failure of the Bankart repair with capsular laxity, and the others experienced capsular laxity alone. In the atraumatic group, all patients experienced capsular laxity as the cause of failure. Of the 14 patients, the capsule quality was judged to be thin in 5 patients and ablated in 1 patient. A glenoid-based capsular shift could be accomplished in all 14 patients. At follow-up (mean, 35.4 months; range, 22 to 48 months), 1 patient underwent revision surgery and 1 patient had a subluxation, resulting in a failure rate of 14%. CONCLUSIONS: Recurrent capsular laxity after failed thermal capsular shrinkage is common and frequently associated with capsular thinning. In most instances, the capsule quality does not appear to technically affect the revision procedure.     

Risk factors for early failure after thermal capsulorrhaphy.

Thermal capsular shrinkage has rapidly become a common procedure for a variety of shoulder conditions usually associated with instability, although clinical data on outcomes are limited. The objective of this study was to identify risk factors for poor outcome after thermal capsulorrhaphy. Of 106 patients who underwent thermal shrinkage, 15 patients with treatment failures were identified. The mean time to failure after the procedure was 6.3 months (range, 1 to 16). Previous operations and multiple recurrent dislocations were associated with poor outcome at a highly significant level. Multidirectional instability and participation in contact sports did not attain statistical significance as risk factors. However, statistical power in these two comparisons was insufficient to exclude them as potential risk factors. A concomitant procedure at the time of thermal capsulorrhaphy was not associated with poor outcome. The data from early treatment failures can be useful in guiding patient selection for thermal capsulorrhaphy. This procedure may be of limited value for patients who have had prior operations or have a history of multiple dislocations. The data also suggest that thermal capsulorrhaphy should be used cautiously in patients with multidirectional instability or in those who are involved in contact sports.     

Arthroscopic versus open Bankart repair for traumatic anterior shoulder instability

After more than 15 years of experience, arthroscopic shoulder stabilization is becoming less controversial. Historically, recurrence rates following arthroscopic stabilization have been higher than with open stabilization. Although a negligible advantage may exist in terms of expedited postoperative rehabilitation and improved postoperative recovery of motion, critics suggest that its use in contact athletes be limited. The indications for arthroscopic stabilization are expanding, in part, because of improved understanding of the pathophysiology of shoulder instability. Understanding the mechanism of recurrent instability following arthroscopic stabilization offers clues to how physicians can prevent unsatisfactory results in the future. With newer instrumentation and the ability to thermally treat capsular tissue, coexisting pathology, such as capsular plastic deformation, rotator interval lesions, and unrecognized intra-articular pathology, can now be addressed arthroscopically. The judicious use of these techniques is warranted until long-term study results become available. Ideal patients for arthroscopic Bankart repair have a discrete Bankart lesion; a robust, well-developed IGHL; no significant capsular laxity or intraligamentous injury; and an absence of concomitant intra-articular pathology. Additional findings on MR imaging or CT evidence of a discrete labral lesion and pure unidirectional anterior instability during EUA are also good prognostic indicators for arthroscopic Bankart repair. Arthroscopic criteria that render patients less appropriate for an arthroscopic repair include capsular injury, capsular laxity, a bony Bankart lesion, glenohumeral arthritis, and a rotator cuff tear. The authors' believe that either absent or patulous, poorly developed glenohumeral ligaments represent a poor prognostic indicator for a successful outcome following standard arthroscopic Bankart repair. Individuals with poor-quality tissue are more predictably managed using open capsulorrhaphy. Patients with pathologic ligamentous laxity in the absence of a Bankart lesion or any apparent intraligamentous injury to the IGHL are also good candidates for treatment with an open capsulorrhaphy. Findings determined from a thorough physical examination, EUA, and the pathology appreciated during diagnostic arthroscopy help to appropriately choose the surgical procedure that effectively addresses pathology in patients who present with recurrent traumatic anterior instability. Patient preferences and surgical experience are important determinants of procedure selection, and current arthroscopic techniques lack the versatility to uniformly address the entire spectrum of pathology that may be associated with traumatic anterior shoulder instability. Surgeons should always be prepared to convert to an open-stabilization technique if the arthroscopic technique is deficient in addressing all pathology identified at the time of surgery.     

Sports ability after Bankart procedure in professional athletes

Recurrent anterior shoulder instability and the restoration of sports ability after surgery are common problems, especially among professional athletes. The purpose of this study was to evaluate the rate, level and time of returning to sports activity after Bankart procedure in anterior shoulder instability in high level atheletes. From 1992–1994 61 patients suffering from recurrent anterior shoulder instability were operated on open Bankart procedure. 44 out of 61 were professional athletes. There were 7 handball, 7 basketball, 6 football, 2 waterpolo and 1 base-ball player and 4 wrestlers, 2 weightlifters, 2 boxers, 3 bicyclists, 2 motorists, 2 swimmers, 2 sailors, 2 kayakers and 2 skiers. The mean duration of instability was 19.1 months (3–72) before operation. 29 patients had posttraumatic recurrent anterior dislocation and 15 patients had posttraumatic anterior subluxations. The average number of redislocations was 4.4, ranging from 2 to 11. At the follow-up examination the patients were tested clinically for instability using the special score created by Walch and Duplay and the Constant functional score. We measured the strength of the rotator cuff by Kintrex isokinetic device from the 10th postoperative week. 35 out of 44 professional athletes could be fellowed-up. The average follow-up period was 14.2 months, from 6 to 31. 88% of the patients were able to return to sports participation, 66% on the previous levels and 22% on a lower level. 12% of the patients finished their professional sports career. The mean rehabilitation period was 5.8 months, the average period of full restoration of sports ability was 9.3 months. Similar results were documented with the Constant score and the Walch-Duplay test (88% excellent or good, 12% fair). The main reason for the inability to continue sports activity was some pain during extreme abduction and extrnal rotation of the arm and recurrent sensations of subluxation (3 cases). Based on the results of the follow-up examinations an early diagnosis is paramount followed by timely surgical intervention to restore anatomical integrity in proven cases of shoulder instability in professional athletes. The open Bankart procedure is preferred giving excellent functional results and providing good chances for the atheletes to return to their previous sports level.     

Arthroscopic anterior shoulder stabilization of collision and contact athletes

BACKGROUND: Repair of the anterior labrum (Bankart lesion) with tightening of the ligaments (capsulorrhaphy) is the recommended treatment for recurrent anterior glenohumeral dislocations. Current evidence suggests that arthroscopic anterior stabilization methods yield similar failure rates for resubluxation and redislocation when compared to open techniques. STUDY DESIGN: Case series; Level of evidence, 4 PURPOSE: To examine the results of arthroscopic anterior shoulder stabilization of high-demand collision and contact athletes. METHODS: Thirteen collision and 5 contact athletes were identified from the senior surgeon's case registry. Analysis was limited to patients younger than 20 years who were involved in collision (football) or contact (wrestling, soccer) athletics. Objective testing included preoperative and postoperative range of motion and stability. Outcome measures included the American Shoulder and Elbow Society shoulder score, Simple Shoulder Test, SF-36, and Rowe scores. The surgical procedure was performed in a consistent manner: suture anchor repair of the displaced labrum, capsulorrhaphy with suture placement supplemented with thermal treatment of the capsule when indicated, and occasional rotator interval closure. Average follow-up was 37 months (range, 24-66 months). RESULTS: Two of 18 contact and collision athletes (11%) experienced recurrent dislocations after the procedure; both were collision athletes. One returned to play 3 years of high school football but failed after diving into a pool. One patient failed in his second season after his stabilization (>2 years) when making a tackle. None of the contact athletes experienced a recurrent dislocation, with all of them returning to high school or college athletics. CONCLUSIONS: One hundred percent of all collision and contact athletes returned to organized high school or college sports. Fifteen percent of those collision athletes had a recurrence, which has not required treatment. Participation in collision and contact athletics is not a contraindication for arthroscopic anterior shoulder stabilization using suture anchors, proper suture placement, capsulorrhaphy, and occasional rotator interval plication.     

Shoulder injuries in overhead athletes. The "dead arm" revisited

The following statements summarize this article: Three distinct categories of Type 2 SLAP lesions exist: (1) anterior, (2) posterior, and (3) combined anteroposterior. Posterior Type 2 SLAP lesions have distinct clinical and anatomic features that distinguish them from anterior Type 2 SLAP lesions. Posterior and combined Type 2 SLAP lesions can be disabling to overhead-throwing athletes because of posterosuperior instability and anteroinferior pseudolaxity. The Jobe relocation test is positive with posterosuperior pain in patients with posterior or combined anterior-posterior Type 2 SLAP lesions and is negative in patients with anterior Type 2 SLAP lesions. Rotator cuff tears are frequently associated with posterior or combined anterior-posterior SLAP lesions, are lesion-location specific, and typically begin from inside the joint as undersurface tears. Repair of posterior SLAP lesions can return overhead-throwing athletes to full overhead athletic functioning. The peel-back mechanism is a likely cause of posterior Type 2 SLAP lesions. To securely repair the posterosuperior labrum to resist torsional peel-back, sulure anchors must be placed posterior to the biceps at the corner of the glenoid. The repair must be protected against external rotation past 0 degree for 3 weeks to avoid undue premature torsional stresses on the repair from the peel-back mechanism. A tight posteroinferior capsule predisposes to Type 2 SLAP lesions in overhead athletes. Shoulders at risk for the dead arm syndrome have a marked loss of internal rotation caused by contracture of the posteroinferior capsule such that less than a 180 degrees arc of rotation is achieved with the arm abducted 90 degrees (the 180 degrees rule). Type 2 SLAP lesions that cause the dead arm syndrome in overhead-throwing athletes are most likely acceleration injuries that occur in late cocking rather than deceleration injuries in follow-through. Rehabilitation of athletes with the dead arm syndrome must include the entire kinetic chain. The root cause of the dead arm syndrome is the Type 2 SLAP lesion.     

Histologic evaluation of the shoulder capsule in normal shoulders,unstable shoulders,and after failed thermal capsulorrhaphy

BACKGROUND: Attenuation of the shoulder capsule has been noted during revision surgery for failed thermal capsulorrhaphy. HYPOTHESIS: The attenuated capsule seen in patients who have undergone failed thermal capsulorrhaphy will show histologic characteristics distinguishing it from the capsule of normal shoulders and dislocating shoulders. STUDY DESIGN: Case control study. METHODS: The shoulder capsules were studied in 12 patients with traumatic anterior instability and in 7 patients who experienced recurrent instability after a thermal capsulorrhaphy. The capsules of six fresh-frozen cadavers with no shoulder lesions were used as controls. RESULTS: Among patients who had a history of traumatic instability, a denuded synovial layer was present in 58%, subsynovial edema in 58%, increased cellularity in 25%, and increased vascularity in 83%. At the time of surgery, five of seven shoulders in the failed thermal capsulorrhaphy group (71%) were subjectively felt to be thin and attenuated. Denuded synovium was found in 100% of these patients, subsynovial edema in 43%, and changes in the collagen layer in 100%. Changes in the collagen layer in these patients included a "hyalinization" appearance in five cases (71%), increased collagen fibrosis in two cases (29%), and increased cellularity in two cases (29%). CONCLUSIONS: There was no one characteristic observable on histologic evaluation that would explain the attenuation of the capsule in cases of failed thermal treatment. Morphologic collagen structure can be histologically abnormal for up to 16 months after thermal capsulorrhaphy.     

Arthroscopic stabilization of posterior shoulder instability

Posterior shoulder instability is a rare and challenging condition with a complex patho-anatomy. The role of arthroscopic repair in the treatment remains poorly defined. The purpose of this study is to evaluate the result of arthroscopic stabilization procedures in patients with posterior shoulder instability. In this case series, we treated eighteen patients (19 shoulders) with posterior shoulder instability with either arthroscopic thermal capsular shrinkage (9 patients), capsulorrhaphy (3) or labral refixation (7). There were eight male and ten female patients with a mean age of 26 years. The study group included unidirectional (6 patients; PI), bi-directional (8; PII) and multidirectional posterior instability (5; MDI). The Rowe-score and DASH-score as well as subjective and objective evaluations of the patients function, range of motion, pain and instability were used as clinical outcome measurements. At a mean follow-up of 50 months, the Rowe-score improved significantly from 46 to 74 (P = 0.005). Four patients (21%) had recurrent instability after arthroscopic treatment (2 with generalized ligamentous laxity; 3 after thermal shrinkage). Analysis of postoperative DASH-scores showed a tendency toward inferior outcomes after thermal shrinkage and in patients with an a-traumatic origin of shoulder instability. We conclude that arthroscopic shoulder stabilization by either labral refixation or capsulorrhaphy is a safe and effective treatment for posterior shoulder instability. Thermal capsular shrinkage however showed poor results and should be abandoned for this indication.     

Return to sport after a Bankart operation of the shoulder using the Mitek® anchor system

Sixteen athletes suffering anteior instability of the shoulder after primary or recurrent traumatic anterior dislocation were followed for a mean of 23.9 months after an open Bankart operation using Mitek® anchors. Nine patients resumed sports an average of 4.4 months postoperatively, while the remaining seven patients did not return to sports at all. By comparing the group of athletes who had resumed sports and the group who had not, we found in the former group a lower mean age, a higher number of athletes who had inflicted their first anterior dislocation during sports and a larger number of people injured on the dominant arm. However, none of the above-mentioned differences were statistically significant, and there were no differences in range of motion, degree of disability or stability of the operated shoulders in the two groups: returned vs. not-returned to sports. All the athletes performing sports at elite-level returned to sports, whereas all the recreational athletes did not. Among the reasons for not resuming sport, 71% gave sociopsychological reasons such as anxiety or lack of time. Two athletes (12.5%) had suffered redislocations after 12 and 19 months, respectively. No complications or other problems related to the use of Mitek anchors were observed.     

Monopolar radiofrequency energy effects on joint capsular tissue: potential treatment for joint instability. An in vivo mechanical, morphological, and biochemical study using an ovine model

The purpose of this study was to evaluate the thermal effect of monopolar radiofrequency energy, a potential treatment means for joint instability, on the mechanical, morphologic, and biochemical properties of joint capsular tissue in an in vivo ovine model. The energy was applied arthroscopically to the synovial surface of the femoropatellar joint capsule of 24 sheep. The sheep were sacrificed at 0, 2, 6, and 12 weeks after surgery (6 per group). Monopolar radiofrequency energy initially caused a significant decrease in tissue stiffness and an increase in tissue relaxation properties, followed by gradual improvement in the tissue's mechanical properties by 6 weeks after surgery. Microscopic examination illustrated that radiofrequency energy initially caused collagen hyalinization and cell necrosis, followed by active tissue repair. Biochemical analysis revealed that treated collagen was significantly more trypsin-susceptibile than untreated collagen at 0 and 2 weeks after surgery, indicating early collagen denaturation. This study demonstrated that this treatment initially caused a significantly deleterious effect on the mechanical properties of the joint capsule, which was associated with partial denaturation of joint capsular tissue. This was followed by gradual improvement of the mechanical, morphologic, and biochemical properties of the tissue over time.     

Percutaneous Techniques for Shoulder Labral Repair

Use of a percutaneous technique for labral repair allows for exact instrument placement, which enhances the ease of tissue preparation and anchor placement. The curved shape of the glenoid can make anchor placement challenging, especially along the inferior aspect of the glenoid. Suture anchors can be placed errantly if soft tissue adjacent to bone, resulting in migration and joint damage. Additionally, percutaneous transtendinous portals minimize the morbidity to the rotator cuff in labral repairs. This is desirable for those athletes with anterior instability to decrease morbidity to the subscapularis and overhead athletes with SLAP lesions to decrease morbidity of the supraspinatus tendon. Finally, when performing capsulorrhaphy, it is also desirable to limit the capsular injury that occurs from utilizing cannulaes for multiple portals.     

Impingement of the rotator cuff in athletes caused by instability of the shoulder joint

An impingement of the rotator cuff can be caused by chronic anterior instability of the shoulder joint. This particular disease is often found in athletes engaged in overhead motion in abduction/external rotation of the arm, such as in ball sports like volleyball or European handball, racket sports like tennis or badminton, or swimming. For those patients that cannot be cured by conservative treatment such as muscular stabilization, surgical treatment is indicated: anterior reconstruction of the capsule and/or the glenoid labrum, and in addition — if necessary — subacromial decompression and revision of the rotator cuff. Between October 1988 and April 1992, we operated on 66 shoulders in 64 top athletes suffering from chronic anterior or multidirectional instability of the shoulder joint that had caused an impingement syndrome of the rotator cuff. In all cases, the athlete was unaware of the instability. Conservative treatment had been unsuccessful. Surgical treatment was successful in close to 90% of the athletes.     

The effects of thermal capsular shrinkage on the outcomes of arthroscopic stabilization for primary anterior shoulder instability

BACKGROUND: The effectiveness of arthroscopic thermal capsulorrhaphy in the prevention of recurrent instability in primary anterior stabilization is undetermined. PURPOSE: To determine if patients with recurrent anterior shoulder instability who have labral repair plus arthroscopic thermal capsulorrhaphy have better outcomes than those with labral repair alone. STUDY DESIGN: Cohort study; Level of evidence, 3. METHOD: There were 72 patients who underwent arthroscopic anterior shoulder stabilization with Suretac II tacks (n = 32) during 1996 to 1999 or with Suretac II tacks plus arthroscopic radiofrequency capsular shrinkage (n = 40) from 1999 to 2002. Standardized patient-determined and examiner-determined outcome measures were obtained preoperatively and at 3, 6, 12, and 24 months postoperatively. Statistical analyses included a Kaplan-Meier analysis of time to recurrent instability. RESULTS: Of the 72 patients, 66 had complete follow-up, including 28 patients treated with the Suretac stabilization and 38 patients with the Suretac plus radiofrequency shrinkage, for a mean follow-up of 58 and 30 months, respectively. All patients had a Bankart lesion. Both groups had similar results with respect to patient-determined and examiner-determined outcome measures. The only adverse outcome was postoperative recurrent instability in 6 of 28 cases in the Suretac group alone and 8 of 38 cases in the Suretac-plus -shrinkage group. Most recurrent instability occurred between 6 and 24 months. Kaplan-Meier analysis for time to recurrent instability showed no differences in the rate of instability recurrence between the 2 groups. CONCLUSION: Arthroscopic thermal capsulorrhaphy neither enhanced nor impaired the outcomes of arthroscopic labral repair with biodegradable tacks in patients with primary recurrent anterior shoulder instability.     

Patterns of glenohumeral joint laxity and stiffness in healthy men and women

PURPOSE: The purpose of this study was to identify gender-related differences in glenohumeral (GH) joint laxity, stiffness, and generalized joint hypermobility in healthy men and women. METHODS: Fifty-one healthy men and women were tested for generalized joint hypermobility, and anterior-posterior (AP) joint laxity and stiffness using a single-group factorial design. RESULTS: Women exhibited significantly more anterior joint laxity (men 8.3 +/- 2.2 mm vs women 11.4 +/- 2.8 mm, P < 0.001) and less anterior joint stiffness (men 20.5 +/- 5.0 N x mm(-1) vs women 16.3 +/- 4.2 N x mm(-1), P < 0.01) than men. Men had significantly more posterior joint laxity than anterior (Ant 8.3 +/- 2.2 mm vs Post 9.6 +/- 2.9 mm; P < 0.001), and women also had significantly less anterior joint stiffness than posterior [Ant 16.3 +/- 4.2 N x mm(-1) vs Post 22.1 +/- 6.9 N x mm(-1); P < 0.01], Women also demonstrated significantly more generalized joint hypermobility than men (men 1.0 +/- 1.7 vs women 2.9 +/- 2.1; P = 0.02). CONCLUSIONS: Our findings may indicate a possible increased risk for instability in women, especially those participating in sports that require repetitive overhead-throwing motion. Future investigations should seek to determine the contribution of increased GH joint laxity and decreased joint stiffness to various injury states and examine these variables in other populations such as overhead-throwing athletes.