Arthroscopic laser-assisted capsular shift in the treatment of patients with multidirectional shoulder instability

BACKGROUND: In recent years, various investigators have begun using lasers in the treatment of shoulder instability. HYPOTHESIS: Arthroscopic laser-assisted capsular shift is an effective treatment for patients with multidirectional shoulder instability. STUDY DESIGN: Retrospective cohort study. METHODS: We retrospectively identified 28 patients (30 shoulders) with multidirectional shoulder instability who were unresponsive to nonoperative management and who had undergone the laser-assisted capsular shift procedure. Twenty-five patients (27 shoulders) with an average follow-up of 28 months were available for review. All patients underwent a physical examination and completed a general questionnaire; the University of California, Los Angeles, shoulder rating scale; the Western Ontario Shoulder Instability Index; and the Short-Form 36 quality of life index. RESULTS: In 22 shoulders, results of the procedure were considered a success because the patients had no recurrent symptoms and at latest follow-up had required no further operative intervention. In five shoulders, results were considered a failure because of recurrent pain or instability and the need for an open capsular shift procedure. With recurrent instability as a measure of failure, the overall success rate was 81.5%. CONCLUSIONS: Our results with laser-assisted capsular shift are comparable with the results of other open and arthroscopic techniques in relieving pain and returning athletes to their premorbid function.     

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.     

A modified capsular shift for atraumatic anterior-inferior shoulder instability

PURPOSE: To evaluate the long-term outcome of a modified inferior capsular shift procedure in patients with atraumatic anterior-inferior shoulder instability by analyzing a consecutive series of patients who had undergone a modified inferior capsular shift for this specific type of shoulder instability. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between 1992 and 1997, 38 shoulders of 35 patients with atraumatic anterior-inferior shoulder instability that were unresponsive to nonoperative management were operated on using a modified capsular shift procedure with longitudinal incision of the capsule medially and a bony fixation of the inferior flap to the glenoid and labrum in the 1 o'clock to 3 o'clock position. The patient study group consisted of 9 men and 26 women with a mean age of 25.4 years (range, 15-55 years) at the time of surgery. The mean follow-up was 7.4 years (range, 4.0-11.4 years); 1 patient was lost to follow-up directly after surgery. The study group was evaluated according to the Rowe score. RESULTS: After 7.4 years, 2 patients experienced a single redislocation or resubluxation, 1 patient had recurrent dislocations, and 1 patient had a positive apprehension sign, which is an overall redislocation rate of 10.5%. The average Rowe score increased to 90.6 (SD = 19.7) points from 36.2 (SD = 13.5) points before surgery. Seventy-two percent of the patients participating in sports returned to their preoperative level of competition. CONCLUSIONS: Results in this series demonstrate the efficacy and durability of a modified capsular shift procedure for the treatment of atraumatic anterior-inferior shoulder instability.     

Laser capsulorrhaphy for multidirectional instability of the shoulder

Multidirectional glenohumeral instability secondary to ligamentous laxity, capsular redundancy, and excessive joint volume occurs frequently. Traditional treatment programs have included conservative care, physical therapy, open surgical stabilization, and arthroscopic techniques. The laser-assisted capsular shift procedure uses low-dose, subablative laser energy to cause shrinkage of the shoulder capsule. The shrinkage of the shoulder capsule results in a decrease in glenohumeral volume improving glenohumeral stability. The Holmium:YAG laser appears to be a useful instrument for the arthroscopic treatment of glenohumeral instability. Holmium:YAG laser energy can be used to thermally modify capsular tissue to cause a reduction in its length without detrimental effects to the viscoelastic properties of the tissue. Early clinical reports have been promising and further follow-up is required to assess the long-term outcome of this procedure.     

Arthroscopic capsulolabroplasty for posteroinferior multidirectional instability of the shoulder

BACKGROUND: Arthroscopic treatment of posteroinferior multidirectional instability of the shoulder is not well documented. PURPOSE: To evaluate pathologic lesions of posteroinferior multidirectional instability and the results of arthroscopic capsulolabroplasty. STUDY DESIGN: Prospective nonrandomized clinical trial. METHODS: Thirty-one patients with posteroinferior multidirectional instability were prospectively evaluated after arthroscopic capsulolabroplasty (mean follow-up, 51 months). Labral lesion and height were measured in the MRI arthrogram and arthroscopic examination. RESULTS: All patients had a labral lesion and variable capsular stretching in the posteroinferior aspect. There were 11 type I labral lesions (incomplete detachment), 12 type II (the Kim's lesion: incomplete and concealed avulsion), 6 type III (chondrolabral erosion), and 2 type IV (flap tear). All patients with type II and III lesions had chondrolabral retroversion, with lost labral height in the MRI arthrogram and arthroscopic examination. Twenty-one patients had an excellent Rowe score, nine had good scores, and one had a fair score. Thirty patients had stable shoulders, and one had recurrent instability. All patients had improved shoulder scores and function and pain scores. CONCLUSIONS: Symptomatic patients with posteroinferior multidirectional instability had posteroinferior labral lesions, including retroversion of the posteroinferior labrum, which were previously unrecognized. Restoration of the labral buttress and capsular tension by arthroscopic capsulolabroplasty successfully stabilized shoulders with posteroinferior multidirectional instability.     

Arthroscopic treatment of synovial chondromatosis that possibly developed after open capsular shift for shoulder instability

Synovial chondromatosis is a rare disease with an unknown etiology, and can be defined as a synovial process characterized by the formation of metaplastic cartilaginous foci inside the connective tissue of articular surfaces. The disease is classified as primary or secondary. The cause of primary disease is unknown, but its pathogenesis involves the development of chondroid foci in synovial membranes. Secondary disease is caused by synovial tissue pathophysiologies, such as, trauma or infection, adjacent to an involved joint. Plain radiographs reveal multiple calcific nodules in glenohumeral joints. However, X-ray diagnosis is often delayed and extremely difficult when the disease is not calcified. Magnetic resonance imaging (MRI) and computed tomography are helpful. For treatment, open or arthroscopic synovectomy and loose body removal are recommended. The authors experienced a rare case of radiologically non-visible synovial chondromatosis, which was viewed as the cause of postoperative residual pain and limitation of motion in a young male with open capsular shift. This case report is presented to emphasize the role of arthroscopy and MRI in the early diagnosis and treatment of synovial chondromatosis.     

Multidirectional shoulder instability. Clinical results of inferior capsular shift in an active-duty population.

We reviewed the results of a capsular shift procedure performed on 10 active-duty patients with an average of 28 months follow-up. Improvement in pain, function, and stability occurred postoperatively in nearly all patients. Loss of total elevation and external rotation were minimal and an average of three spinal segments of internal rotation were lost. Only one patient required further surgery for recurrent instability and all patients except two reported over-all improvement. Dominant shoulders made greater improvements in pain, stability, and functional capacity than nondominant shoulders. Patients with generalized ligamentous laxity had less pain and more posterior instability than those without laxity. A history of an acute traumatic event was predictive of greater improvement in pain and stability. A previous instability repair was indicative of the most postoperative instability and least functional improvement.     

Arthroscopic capsular plication formultidirectional instability of the shoulder

Involuntary multidirectional instability of the shoulder remains one of the most challenging problems for the orthopedic surgeon. Often these patients are young and athletic, with very high goals for their shoulder function. During the past two decades, the inferior capsular shift procedure has become the surgical mainstay when conservative treatment fails. Various investigators have published techniques for capsular shift, either for the humeral side or glenoid side, with satisfactory results for each. This article reviews our experience with a new technique developed by SJS for arthroscopic capsular plication of the shoulder. A review of the literature, surgical technique, postoperative rehabilitation and results are presented.     

Recurrent shoulder instability after open reconstruction in athletes involved in collision and contact sports

The purpose of this study was to evaluate the incidence of recurrent instability in a group of young athletes who underwent open shoulder stabilization with a modified Bankart repair and anterior capsulorrhaphy. Recurrent dislocation was defined as an instability episode resulting in complete dislocation requiring manual reduction. Recurrent subluxation was defined as the subjective history of the shoulder "slipping or popping out" or pain and apprehension that caused cessation of athletics for at least 1 day. Sixty-six patients (64 men and 2 women) were included in the study. A collision sport precipitated instability in 53 patients and a contact sport in 13. The average follow-up was 47 months (range, 24 to 72). The average American Shoulder and Elbow Surgeons score was 95 points (range, 71 to 100). The average Rowe score was 80 points (range, 40 to 100). Two patients had experienced recurrent dislocation after surgery (3%). Eight patients (12%) had rare (fewer than three) episodes of postsurgical subluxation. Five patients (8%) had multiple recurrent subluxations after surgery. Postsurgical recurrent instability was significantly associated with preoperative episodes of subluxation. However, all patients with rare subluxation had an excellent functional result.     

Advances in the management of traumatic anterior and atraumatic multidirectional shoulder instability

Dislocation of the shoulder is a common and often disabling injury to an athlete. Most shoulder dislocations are traumatic in origin, occur in the anterior direction and result in stretching and detachment of the anterior capsule and labrum. The most frequent adverse sequel of shoulder dislocation is recurrence--an event that occurs most commonly in active individuals and less frequently with age. In the past, many operative procedures failed to address the anatomical disruptions of shoulder instability. Recently, an enhanced understanding of shoulder instability pathoanatomy and significant technological advances have resulted in surgical procedures for shoulder instability that are less interventional and have focused on restoring disrupted static constraints.     

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.     

Anteromedial capsular redundancy and labral deficiency in shoulder instability

BACKGROUND: Redundancy of the anteromedial capsule of the shoulder may persist despite proper tensioning of the capsule and repair of a Bankart lesion during an anteroinferior capsular shift procedure. HYPOTHESIS: A barrel-stitch suture technique incorporated into a capsular shift procedure is effective in achieving satisfactory shoulder stability. STUDY DESIGN: Uncontrolled retrospective review. METHODS: A barrel-stitch technique was used for patients identified as having anteromedial capsular redundancy during a capsular shift procedure for anteroinferior instability. RESULTS: The incidence of anteromedial capsular redundancy and labral deficiency was 49% (38 of 78). Patients with anteromedial capsular redundancy had a significantly greater number of dislocations before surgery (16.1 +/- 21.3 versus 7.4 +/- 7.4) and a greater duration of symptoms (79.8 +/- 84.2 versus 31.6 +/- 32.2 months). The mean postoperative Rowe score of patients with anteromedial capsular redundancy was 88.7 +/- 14.8, with 92% having excellent or good results, compared with 88.9 +/- 14.8 in the remaining patients and 93% excellent or good results. CONCLUSIONS: Anteromedial capsular redundancy is associated with longer preoperative duration of symptoms and more dislocations, but effective treatment can be achieved with a capsular shift procedure augmented with medial capsular imbrication with a barrel stitch.     

Selective capsular shift technique for anterior and anterior-inferior glenohumeral instability

Anterior and anterior-inferior glenohumeral instability is often successfully treated with nonoperative measures, especially in atraumatic instability. In the case of traumatic instability, especially when the labrum is detached from the anteroinferior glenoid rim, surgery is often necessary to stabilize the shoulder and restore function. An anatomic repair that addresses any capsular or labral defect is essential for a successful outcome, and the selective capsular shift technique offers the flexibility necessary to correct these deformities. Several equally important steps must be followed when treating anterior and anterior-inferior glenohumeral instability. These include the correct diagnosis and indications for surgery; a technically successful surgical procedure; and diligent, physician-directed, closely monitored rehabilitation.     

Biomechanical stability of an arthroscopic anterior capsular shift and suture anchor repair in anterior shoulder instability: a human cadaveric shoulder model

It was hypothesized that an arthroscopic Bankart repair with suture anchors supplies sufficient anterior shoulder stability, which cannot be improved by an additional capsular shift. In an experimental biomechanical human cadaver study, we tested ten fresh human cadaver shoulders in a robot-assisted shoulder simulator. External rotation and glenohumeral translation were measured at 0° and 80° of glenohumeral abduction. All measurements were performed under the following conditions: on the non-operated shoulder; following the setting of three arthroscopic portals; following an arthroscopic anterior capsular shift; following a simulated Bankart lesion; and following an arthroscopic Bankart repair. The application of three arthroscopic portals resulted in a significant increase of the anterior (P = 0.01) and antero-inferior translation (P = 0.03) at 0° and 80° abduction, as well as an increase in external rotation at 80° abduction (P = 0.03). Capsular shift reduced external rotation (P = 0.03), but did not significantly decrease translation. Simulating anterior shoulder instability, glenohumeral translation significantly increased, ranging from 50 to 279% of physiological translation. Arthroscopic shoulder stabilization resulted in a decrease of translation in all tested directions to approximately physiologic levels. External rotation in 0° abduction was thus decreased significantly (P = 0.003) to an average of 19°. The study proved that an arthroscopic anterior capsular shift in a cadaveric model decreases external rotation without a significant influence on glenohumeral translation. Arthroscopic shoulder stabilization with suture anchors thus sufficiently restores increased glenohumeral translation, but also decreases external rotation in neutral abduction. An anatomic reconstruction of the Bankart lesion without overconstraining of the antero-inferior capsule should therefore be the aim in arthroscopic anterior shoulder stabilization.     

Kinematic and muscle activity characteristics of multidirectional shoulder joint instability during elevation

Alterations of shoulder motion have been suggested to be associated with shoulder disorders. The objective of this study was to perform a 3D motion analysis (kinematic and electromyographical) of skeletal elements and muscles of shoulder joint in patients with multidirectional instability. Fifteen patients with multidirectional instability and 15 normal controls were investigated during continuous elevation in the scapular plane. The spatial coordinates of 16 anatomical points of the shoulder to determine kinematical parameters were quantified by an ultrasound-based motion analyzer. The activities of 12 muscles were measured by surface electromyography. Kinematic characteristics of motion were identified by scapulothoracic, glenohumeral, and humeral elevation angles; range of angles; scapulothoracic and glenohumeral rhythm; scapulothoracis, glenohumeral, and scapuloglenoid ratios; and the relative displacement between the rotation centers of the humerus and the scapula. The electromyographical characteristics of motion were modeled by the on–off pattern of muscle activity. Significant alterations in kinematical parameters were observed between patients and asymptomatic volunteers. The anterior, posterior, and inferior dislocations of shoulders with multidirectional instability could be properly modeled by the relative displacement between the rotation centers of the scapula and humerus. The shorter activity by m. pectoralis maior and all three parts of m. deltoideus and longer activity by m. supraspinatus, m. biceps brachii, and m. infraspinatus assure the centralization of the glenuhumeral head of a shoulder with multidirectional instability.     

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.