Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Multidirectional Glenohumeral Instability Treatment & Management

  • Author: Daniel C Wnorowski, MD, MBA; Chief Editor: S Ashfaq Hasan, MD  more...
 
Updated: Jan 15, 2016
 

Approach Considerations

Indications for surgical treatment of multidirectional instability (MDI) include the presence of persistent symptoms to a disabling degree and failure of conservative management, including a supervised rehabilitation program and a trial of activity modification or restriction. A reasonable trial of conservative treatment is 3-6 months. (See Nonoperative Management below.)  Any patient for whom conservative management has failed may be counseled regarding the option of surgical treatment. The following points must be considered:

According to Neer and Foster,[14] contraindications for surgical management of MDI include the following:

  • Willful, habitual, or voluntary shoulder instability
  • Collagen connective tissue disorders (eg, Ehlers-Danlos syndrome, Marfan syndrome)
  • Lack of a trial of, or noncompliance with, a supervised rehabilitation program

Future and controversies

Areas of future development in the treatment of MDI likely will parallel the further development of operative shoulder arthroscopy. The trend has been to drift away from open surgery, and it is very likely that this will continue. This trend is driven by patient and surgeon perceptions of less surgical invasiveness and reduced morbidity associated with arthroscopic techniques. However, it remains to be seen whether the effectiveness of arthroscopic management approaches that of the conventional open capsular shift technique, particularly after long-term follow-up. For now, it is wise to advise patients that the results of arthroscopic stabilization for MDI may be discounted relative to open surgery, at least in the long run.

Experience with thermal stabilization has mirrored that of thermal chondroplasty. These procedures have been mostly abandoned. Significant complications, including chondrolysis, capsular necrosis, tendon rupture, adhesive capsulitis, and axillary nerve injury, have been reported. The use of this technique grew rapidly, perhaps because it was relatively easy to perform, and also because it avoided arthroscopic knot-tying. Although basic science studies underscore the apparent effectiveness of thermal stabilization in decreasing capsular laxity, clinical studies have not shown satisfactory results.

With regard to arthroscopic suture techniques, increasing basic science data are available that favorably compare the effectiveness of this evolving stabilization technique with the customary open shift. There are many questions, including where to place sutures, how many sutures to use, whether to use absorbable versus nonabsorbable sutures, how tight the plication should be, and what rehabilitation modifications are necessary.

Whether arthroscopic suture techniques can mimic an open shift repair over the long term remains unknown, but early clinical results appear promising. The possibility of overconstraining the joint must also be considered. Again, more work is needed to continue to support the general use of this approach over its open counterpart.

Next

Nonoperative Management

Neer and Foster[14] stressed the importance of conservative management before surgery. In their original case series, the patients they selected for surgery had symptoms and disability for 1 year and had also undergone a trial of rotator-cuff and deltoid rehabilitation that failed. Furthermore, Neer and Foster carefully excluded patients with emotional problems (now referred to as intentional, habitual, and willful voluntary dislocators).[14]

Many patients respond positively to a supervised vigorous shoulder-conditioning program. Supervision is essential, at least initially, to ensure both compliance and effective instruction in the proper execution of an exercise program. Exercises should address all portions of the rotator cuff. A low-resistance, high-repetition, subimpingement-range, isotonic cuff-strengthening program works well with use of stretch cords or hand weights. These exercises are most beneficial when performed three to five times per week.

Isokinetic equipment is useful but not essential; this equipment is helpful for interval testing to assess progress. The most important factor is to teach the patient the value of a persistent, ongoing effort at shoulder-girdle strengthening (ie, strengthening for life). Many patients initially do well with their exercise program but then lose discipline when symptoms subside—with recurrences subsequently following. Most patients learn to return to conditioning exercises when symptoms return.

In addition to a strengthening program, activity modification is necessary to eliminate, or at least reduce, pain and instability symptoms. Avoidance of unnecessary overhead motions (eg, throwing, racquet sports, swimming), side carrying and lifting, and pushing and pulling may be required. Work modifications also may be considered.

Anti-inflammatory medications or analgesics may help during exacerbations of MDI. Steroid injections have a limited place in the nonoperative treatment of MDI but may be helpful in the treatment of secondary impingement syndrome. Narcotic medications have no place in the management of MDI.

A reasonable duration for conservative treatment is 3-6 months; any patient in whom conservative treatment has failed may be counseled regarding the option of surgical treatment. The following points must be considered:

  • Does the patient have sufficient disability to make surgery a worthwhile endeavor?
  • Has the patient shown satisfactory effort and dedication to the preoperative rehabilitation program?
  • Is the patient willing to continue postoperative rehabilitation for at least 6 months, and does he/she understand the importance of shoulder rehabilitation and muscle strengthening to the stability of the shoulder?
  • Is the patient willing to comply with postoperative limitations such as immobilization, activity limits, and work and sports restrictions?
  • Is the patient willing to accept the possibility of lost range of motion (ROM)?
  • Is the patient willing to risk axillary nerve injury?
  • Is the patient willing to accept the possibility of recurrent symptoms (ie, failure of the procedure)?
Previous
Next

Options for Surgical Management

This author currently uses a traditional open surgical approach for severe MDI; uses an arthroscopic plication technique for mild-to-moderate MDI, as well as for anteroinferior-predominant and posteroinferior-predominant MDI; and does not use or advocate thermal treatment, in light of reported complications, especially with the risk of axillary nerve injury, the potential for capsular necrosis (see Complications below), and the reports of poor results.[13]

Key elements of the various options are discussed below.

Open surgical management

The landmark paper on MDI was that of Neer and Foster, published in 1980.[14] Not only did this classic paper facilitate widespread recognition of the MDI problem that was previously believed to be rare relative to unidirectional instability, but it also described a capsulorrhaphy to address the pathologic capsular laxity associated with MDI.

Of the 32 patients in this study, 31 (97%) had satisfactory results following the inferior capsular shift procedure with no recurrent instability, no significant postoperative pain, full strength, and full return to activity.[14] However, this was a preliminary study; by today's standards, ROM was questionable, with satisfactory defined as ROM within 10° of elevation and 40° of rotation of the contralateral side.

A biomechanical study by Wang et al[27] of joint reactive forces and glenohumeral translations in a cadaveric model reported that the inferior capsular shift was superior to a unidirectional anterior capsular repair in reproducing more normal forces, kinematics, and mechanics.

In a follow-up report by Neer and Foster,[28] the longevity of the results of the inferior capsular shift procedure for MDI was documented in larger numbers of patients with longer follow-up.

Other reports of the use of the inferior capsular shift procedure for MDI were published early in the learning curve. Recurrence rates consistently were reported at 10% or less.[15, 29, 30, 16] However, average loss of motion has remained variable, with the best cited as only 6° of elevation loss and 3° of external rotation loss in a series of active-duty naval personnel at 28 months,[16] and only 5° and 4° of external rotation loss at 0° and 90° of abduction, respectively, at 36 months.[30] Postoperative ROM obviously varies from patient to patient and surgeon to surgeon, and it is likely to also be a function of the rehabilitation program.

The classic Neer-type inferior capsular shift has been modified by making the shift in the glenoid side, rather than the humeral side, and by applying it to patients with a predominantly anterior-inferior instability pattern. In 42 shoulders, of which 90% had a concomitant Bankart repair and 50% had generalized ligamentous laxity, four (9.5%) had recurrent instability.[30] Interestingly, three of these four (7.1% of 42) had recurrent posterior instability. However, in the successful category, motion loss was relatively small, averaging only 5° of external rotation, with no more than 5° of elevation loss.

The classic humeral side inferior capsular shift procedure has been applied to lesser degrees of MDI as well. The procedure has also held up well in patients who are very active.

Bigliani et al[31] reviewed 63 patients, in whom a combined total of 68 inferior capsular shifts had been performed. Most were performed primarily for anterior-inferior instability, excluding combined anterior and posterior patholaxity and associated glenoid fractures. These patients were athletic, including 31 throwers, and 21 (30.9%) of these surgeries also included a Bankart procedure.

Results were good to excellent in 94% of the cases, with 92% of patients able to return to their previous sports.[31] However, only 75% of the patients were able to return at their previous level of play (only five of 10 were elite throwers). Motion loss was less than in Neer and Foster's series, averaging only 7° of lost external rotation. Two patients (3.2%) had redislocations resulting from falls, one (1.6%) had musculocutaneous nerve palsy that resolved, and 10% of patients had persistent minor clicking.

Arthroscopic management

It is only comparatively recently that the use of the arthroscope in the setting of MDI has made the transition from the diagnostic to the operative realm. Snyder's 1994 textbook, Shoulder Arthroscopy, makes no mention of arthroscopic management techniques for MDI, but he describes the diagnostic findings at arthroscopy.[32] He stated, "If surgery is required for atraumatic laxity, most often an open capsular shift procedure is used." He refers the reader to Neer and Foster's classic 1980 paper.[14]

However, various options are still evolving for arthroscopic management of MDI. The same basic principles of open surgery apply. The goals are as follows[33] :

  • Reduction of overall capsular patholaxity anteriorly, posteriorly, and inferiorly
  • Closure of the rotator-cuff interval
  • Minimization of morbidity and risk of complications

Thermal capsulorrhaphy

Thermal or radiofrequency (RF) "capsular shrinkage" was advocated in the past because of its technical ease and simplicity relative to traditional open capsulorrhaphy or arthroscopic suture techniques.

Abundant basic science research has shown that RF energy applied to collagen tissues results in shortening proportional to temperature and duration of contact,[34, 35, 36, 37, 38, 39] as well as ultrastructural changes[40] , in energy and time-dependent fashions.[41, 42]  Technique-dependent[43] temporary decreases in strength and stiffness of treated capsular tissue[44]  have been demonstrated and are likely the basis for observed mixed clinical results, with high failure rates (up to 60%) reported in some cases.[45, 13, 18, 19]

This technique has largely been abandoned.

Arthroscopic suture plication (suture capsulorrhaphy)

Results of arthroscopic suture management of MDI are premature, and long-term follow-up is pending. Snyder[12] reported on 23 of 24 patients who had a capsular plication for glenohumeral instability in the absence of a Bankart lesion. He noted that MDI was present in eight of the 23 seen for follow-up at an average of more than 24 months. American shoulder and elbow system (ASES) scores improved on average, and Rowe scores were good or excellent in 78% of cases. Snyder termed this technique a promising alternative to open techniques. For further information, see Shafer et al.[46]

Wolf and Durkin[11] presented their results of suture plication in 20 of 26 patients with average 34-month follow-up (minimum follow-up, 24 months). With regard to pain, strength, activity, ROM, stability, and overall satisfaction, results were good to excellent in 75% of cases. Workers' compensation claims correlated with unsatisfactory outcome, and five patients with recurrent instability required a total of eight additional surgical procedures.

Treacy et al[17] reported their results of an arthroscopic capsular shift for MDI in 26 patients and noted 88% satisfactory results in 24 patients available for review at an average of 52 months (range, 28-72 months). Three patients had postoperative instability. All but one of the 24 patients had regained full symmetrical ROM. The authors felt that these results were comparable to the results of open surgery.

Two clinical studies reported 2- to 5-year results. Gartsman et al[47] evaluated 47 patients with MDI managed with arthroscopic plication with or without interval closure, reporting 94% good-to-excellent Rowe scores accompanied by a significant increase in UCLA shoulder score, with 86% return to sports. Baker et al[48] also demonstrated similar functional improvements and high rate of return to athletic activities after arthroscopic management of MDI.

A review article by Caprise and Sekiya[49] is worthy of mention and comment. The authors stress that although arthroscopic suture techniques for the treatment of MDI are new and evolving, these methods "have comparable results to open techniques when the multifactorial nature of the disease is recognized and the multiple techniques are used in combination to fully treat all pathology.... The advantages of a less invasive procedure make arthroscopic capsular plication attractive, but it is associated with increased technical difficulty and a steep learning curve."

Caprise and Sekiya stressed that further research and follow-up are needed, and they emphasized that the goal of any surgery for MDI, whether open or arthroscopic, is "addressing the capsular laxity and redundancy to restore anatomic capsuloligamentous tension without overconstraining the shoulder."[49]

Cadaveric studies have shed light on the effects of capsular plication on capsular tightness.[46] Gerber et al[50] studied the effects of selective capsular plications on the ROM of the shoulder in eight cadaveric specimens and found predictable patterns of motion loss. Medial-to-lateral 1-cm plications resulted in significant losses of motion, as follows:

  • Anterosuperior plication, 30.1° loss of external rotation in adduction
  • Anteroinferior plication,19.4° loss of abduction and 20.6° loss of external rotation
  • Posterosuperior plication, 16.1° loss of internal rotation in adduction

Furthermore, total anterior and total posterior plication resulted in loss of flexion of 20° and abduction of more than 15°, whereas total anterior plication had a greater than 30° loss of external rotation and total posterior plication had a greater than 20° loss of internal rotation.[50] Finally, total inferior plication resulted in loss of abduction of 27.7°.

Alberta et al[51] found that in six cadaveric specimens that underwent "stretching" of the anteroinferior capsule that resulted in increased external rotation of 23.2° without increased glenohumeral translation, selective anteroinferior plication reduced this external rotation by more than 12°. The center of rotation of the glenohumeral joint (GHJ) was posteriorly and inferiorly shifted, with loss of anterior translation 49-61%, at 15N and 20N loads, respectively. Finally, the capsulolabral "bumper" height more than doubled, from 2.9 mm to 6.4 mm. Such observed restrictions of motion may improve clinical instability but may have consequences for the long-term function of the GHJ.

Flanigan et al[52] found losses of cadaveric capsular volumes of 16.2% and 33.7% with 5- and 10-mm plications. Sekiya et al[53] found cadaveric capsular volume decreases greater than open techniques when "multiple pleats" were taken, mirroring arthroscopic techniques.

There has been evidence that aggressive tightening, especially with interval closures, may limit ROM, especially external rotation.[54, 55]

Thus, these techniques carry a degree of subjective judgment, and more research is necessary to delineate guidelines for appropriate tightening.

Previous
Next

Technical Details: Open Surgery

This discussion of the open surgical technique focuses first on the classic treatment for MDI, followed by modifications. Useful and recommended modifications are in parentheses.

Neer and Foster[14] emphasized the basic principle of capsular detachment from the humeral neck on the predominant side of instability and then shifting the capsule to the opposite side of the calcar. The goals are to reduce the capsular redundancies on the more-involved approach side and also on the opposite side, while additionally obliterating the axillary pouch. Neer and Foster also emphasized the creation of thickenings in the repaired shifted capsule by folding and overlapping capsular flaps. Permanent nonabsorbable sutures are used.

After a thorough examination under anesthesia (EUA) to elucidate the dominant direction of instability, the patient is placed in a beach-chair position for a planned anterior approach. If arthroscopy is performed before a planned open anterior approach, it is useful to perform the arthroscopic segment in the beach-chair position as well. If a posterior approach is planned, arthroscopy is best performed in a lateral position, with open surgery continuing via a posterior approach in the same position.

In other words, the surgical position should be clear following EUA, with patient position maintained through both the arthroscopic and open portions of the procedure. In this author's experience, arthroscopic findings rarely change the plan following EUA.

For severe MDI, both anterior and posterior aspects of the shoulder are exposed, and a deltopectoral approach is planned. A 9-cm incision is made from the axillary crease distally to the coracoid proximally. (This is a long incision and is rarely necessary. In fact, an axillary incision measuring more than 4 cm is sufficient in a patient who is relatively slim. See the images below.)

Cosmetically ideal modified axillary incision for Cosmetically ideal modified axillary incision for open inferior capsular shift. Incision will be made in apex of axillary crease. Photo courtesy of Daniel C Wnorowski, MD.
Open approach via axillary incision. Self-retainin Open approach via axillary incision. Self-retaining retractor is shifted cephalad after mobilization of skin flaps. Photo courtesy of Daniel C Wnorowski, MD.

The interval between the deltoid and pectoralis major muscles is identified, as well as the cephalic vein, which then is retracted medially. (Take the vein in any direction it wants to follow.) Retract the conjoined tendon medially. (Respect the musculocutaneous nerve, which typically penetrates the conjoined tendon 3-5 cm below the coracoid process.)

The subscapularis tendon is identified. Cauterize the vessels at their lower margins, superficial to the subscapularis. Neer and Foster recommended next dividing the superficial one-half thickness of the subscapularis tendon 1 cm medial to the long head of the biceps, whereas the deeper one-half thickness is left on the capsule for reinforcement. (It is wise to leave slightly more [1.5 cm] lateral subscapularis tendon.)

The medial subscapularis flap is tagged, dissected from its deeper component, and retracted medially. (The lower third of the subscapularis tendon is mostly muscle, with minimal tendon fibers.) The underlying capsule is inspected, and the interval between superior and middle glenohumeral ligaments is closed with nonabsorbable sutures (see the image above). (This is a constant finding, and the rotator-cuff interval closure is essential to reduce inferior glenohumeral translation, but it may be difficult to reach with a very small incision in the axilla.)

Next, a T-shaped incision is made in the capsule, with the stem of the T aimed at the glenoid, traversing the interval between the middle and inferior glenohumeral ligaments, and the top of the T parallel to the humeral anatomic neck (1 cm from its lateral insertion). Two capsular flaps thereby are created, one superomedial (SM) and the other inferomedial (IM) (see the images below). During exposure and repair, it is very helpful to tag each flap corner with a long suture to control the flaps.

Rotator-cuff interval is closed with nonabsorbable Rotator-cuff interval is closed with nonabsorbable suture. T-capsulotomy incision is planned with dotted lines.
Superomedial (SM) and inferomedial (IM) flaps crea Superomedial (SM) and inferomedial (IM) flaps created by T-capsulotomy incision. First, IM flap will be advanced superiorly and laterally; then, SM flap will be advanced inferiorly over top of IM flap.

The proximal-distal incision is gradually extended distally, dividing the IM flap from the inferior humeral neck around to the posterior portion of the neck, while carefully protecting the axillary nerve with a flat retractor. To assist in control of the flap and to aid in visualization, it is helpful to place nonabsorbable sutures at 1-cm intervals in the lateral margin of the IM flap while progressing distally; the sutures will be used in the repair on the way out.

Once the dissection reaches the posterior portion of the capsule and humeral neck, it is useful to apply traction to the IM flap in order to test the effect of capsular shortening on posterior capsular tension and to estimate and adjust necessary capsular repair tension.

With a gauge or curette (a rongeur works well), a shallow groove is then fashioned in the anterior-inferior portion of the humeral neck adjacent to the capsular reflection. Then, the IM flap is advanced in a proximal direction to eliminate the inferior pouch and increase posterior tension. The lateral edge of the IM flap of the capsule is sutured to the remnant lateral capsular tag or adjacent subscapularis stump (by using the aforementioned sutures). Once this has been accomplished with the IM flap, any redundant superior portion may be reflected inferiorly to thicken the anterior capsule.

Finally, the SM flap is advanced distally and inferiorly and similarly sutured to the superior and anterior lateral capsular remnant and subscapularis stump.

An overlap develops as the SM flap is advanced inferiorly. This overlap serves to further reinforce the anterior tissues (see the image below). Neer and Foster recommended securing the capsule with the arm in slight forward flexion and at about 10° of external rotation. To avoid excessive tension, this author secures the repair sutures with the arm in at least 45° of abduction and 45° of external rotation.

Finished repair with superomedial (SM) flap advanc Finished repair with superomedial (SM) flap advanced inferiorly, overlapping previous inferomedial (IM) flap advancement. Note how axillary pouch has been eliminated.

The subscapularis tendon is closed at its normal location, with care taken to avoid shortening anatomically. Matsen et al[10] showed that a shortening of 1 cm can theoretically limit rotation by 20°. After the remaining closure is finished, the arm is immobilized at the side in a splint or a sling with a chest pad on neutral flexion and 20° of internal rotation.

For the posterior-inferior predominant instability pattern, a posterior approach may be chosen. One trend has been to perform all shifts from the front; the reasoning behind this is that the rotator-cuff interval cannot be closed from the back, and reasonable posterior tightening can be obtained from the front.

For a posterior approach, according to Neer and Foster, a 10-cm incision is made either horizontally or vertically over the posterior-lateral scapular spine and posterior glenohumeral joint. They recommended detachment of the deltoid from the posterior acromion and scapular spine, followed by a vertical 2- to 3-cm split to expose the underlying external rotators. However, detachment of the deltoid can usually be avoided, in that it can be more simply retracted upward.

As with the dissection of the subscapularis anteriorly as described above, the infraspinatus is divided near its insertion and peeled medially, leaving some of its fibers on the posterior capsule for reinforcement. The posterior capsule normally is very thin posteriorly; hence, this step is important.

Again, a T-shaped capsulotomy is made, creating SM and IM flaps. The IM flap is dissected and released progressively around the inferior humeral neck in an anterior direction while the axillary nerve is carefully protected throughout. A trough is prepared on the posterior-inferior humeral neck. Eventually, the IM flap is advanced and repaired gradually in a superior direction, eliminating both anterior patholaxity and the axillary recess. Then, the SM flap is advanced over the top of the IM flap to reinforce and add bulk to the middle posterior capsule. Afterward, the infraspinatus is repaired in an anatomic fashion, followed by the posterior deltoid.

The arm is immobilized in neutral flexion-extension and 10° of external rotation for 6 weeks. This author generally immobilizes the arm in 30°-45° of abduction and 30° of external rotation for 4 weeks, followed by a 1-week transition to the Neer and Foster position, followed by a sling.

Previous
Next

Technical Details: Arthroscopic Surgery

As recently as 1994, the role of the arthroscope in the evaluation and management of MDI was limited to a diagnostic function.[32] Since then, however, as with other shoulder applications, operative arthroscopy for MDI has been developing and evolving rapidly.

Operative arthroscopy for MDI can be used for either primary or adjunctive functions. Open surgery—namely, the open capsular shift—is predictable, safe, and successful, with a proven track record. Thus, any new arthroscopic approaches must be compared to open surgery with regard to efficacy and safety. The general principles of open surgical treatment must be addressed via arthroscopic means. Furthermore, should arthroscopic approaches prove easier, as well as effective and safe, they must not displace or preempt a routine trial of conservative management before consideration of surgical treatment.

Arthroscopic stabilization of the MDI shoulder can be performed in either the beach-chair or the lateral position. A thorough EUA must precede diagnostic arthroscopy. Routine utilitarian portals are established. The posterior portal is made 1.5 cm distal and medial to the posterior-lateral corner of the acromion; the anterior portal is made1.5 cm medial and proximal to the coracoid process, between the long head of the biceps and the upper edge of the subscapularis intra-articularly.

Arthroscopic suture repair techniques were developed by Snyder,[12] who called this approach "capsular pinch-tuck," or "plication surgery." The arm position is lateral, at 70° abduction and 10° flexion. Two anterior portals in the rotator-cuff interval are created, as well as a posterior superior portal. The synovial surfaces are excoriated on the capsule and adjacent areas of the labrum.

While the surgeon views from the posterior portal and uses a suture hook through one of the anterior portals, a pinch-tuck of capsular tissue is taken 1 cm lateral to the labrum, and the needle and tissue are approximated to the edge of the labrum.[12] The needle is then passed through the labrum (it has now captured both the capsule and labrum). First, a suture relay is passed through the suture hook; then a suture is passed via the relay in the opposite direction out the original cannula. This thus leaves a suture crossing the labrum and also through the capsular fold.

The process is repeated at 1-cm intervals along the labrum in an inferior direction; each suture is tied with an arthroscopic knot pusher by a sliding knot technique (Snyder recommended the Tennessee slider knot).[12] The number of tucks and the extent of anterior, inferior, and posterior tightening are left to the individual surgeon's judgment. Snyder warned that the axillary nerve is at risk with a deep pass through the inferior capsule.

The images below show posterior plication and are representative. The view is of a left shoulder from the anterosuperior portal, just anterior to the biceps long head, aimed in a posteroinferior direction. The patient is in the lateral decubitus position, with the arm in 5 lb of traction, positioned in 45° of abduction and 20° of forward flexion. The working portal is the typical posterior portal, which is 1.5 cm inferior and 1.5 cm medial to the posterior corner of the acromion.

First, a suture passer device (Spectrum; ConMed Linvatec, Largo, FL) is placed through the working cannula; next, it is initially passed through a pinch of posterior capsule 1 cm from the labrum and then through the posterior labrum itself (see the image below).

Suture passer device (Spectrum; ConMed Linvatec, L Suture passer device (Spectrum; ConMed Linvatec, Largo, FL) is placed through working cannula, then through "pinch" of posterior capsule, and also through posterior labrum. Photo courtesy of Daniel C Wnorowski, MD.

Next, with monofilament suture employed in an all-arthroscopic knot-tying technique (sliding knot first, backed up by an alternating post, alternating half-hitch technique), a knot is tied, plicating the capsular pinch to the labrum (see the image below).

Next, with monofilament suture and all-arthroscopi Next, with monofilament suture and all-arthroscopic knot-tying technique, knot is tied, thus plicating capsular "pinch" to labrum. Photo courtesy of Daniel C Wnorowski, MD.

The process is repeated to place a second, slightly more superior suture and knot (see the images below). Capsular pinches or tucks may vary at the surgeon's discretion, and the number of sutures and the spacing between sutures also may vary (1-cm spacing is typical; see the images below). Caution is advised in passing sutures in the inferior regions anteriorly and posteriorly, given the proximity of the axillary nerve to the inferior capsule. It is best to avoid passing sutures altogether between the 5- and 6-o'clock positions.

Process in image above is repeated to place second Process in image above is repeated to place second, slightly more superior suture and knot. Photo courtesy of Daniel C Wnorowski, MD.
Close-up of third "pinch." Photo courtesy of Danie Close-up of third "pinch." Photo courtesy of Daniel C Wnorowski, MD.
Close-up of third labral pass. Photo courtesy of D Close-up of third labral pass. Photo courtesy of Daniel C Wnorowski, MD.
Third suture is placed. Photo courtesy of Daniel C Third suture is placed. Photo courtesy of Daniel C Wnorowski, MD.
Completed third knot. Photo courtesy of Daniel C W Completed third knot. Photo courtesy of Daniel C Wnorowski, MD.
Depending on degree of capsular laxity, one may ta Depending on degree of capsular laxity, one may take "double tuck" to achieve additional plication and tightening, at risk of added range of motion restriction. Photo courtesy of Daniel C Wnorowski, MD.

An arthroscopic interval closure is also typically added to reduce inferior laxity; this may be done last, after completion of plication sutures (see the images below).

View from posterior portal of "interval closure"; View from posterior portal of "interval closure"; with suture passer device, monofilament suture is placed at margins of cuff interval. Photo courtesy of Daniel C Wnorowski, MD.
Knot is tied through anterosuperior portal, thus c Knot is tied through anterosuperior portal, thus closing rotator-cuff interval. Photo courtesy of Daniel C Wnorowski, MD.

Sometimes, the labrum may be deficient, hypoplastic, abraded, or torn and thus insufficient for use via direct suture passage technique. In such a situation, suture anchors may be helpful (see the images below). The anchor is placed on the margin of the articular surface, and the attached suture is then passed through the capsule to achieve a standard "tuck," with or without the labrum if possible, to achieve a "caposulolabral reconstruction" and a "bumper-stop" configuration, to enhance stability.

Second of two anchors placed for posterior plicati Second of two anchors placed for posterior plication, given hypoplastic posterior labrum, prior to suture passage. Note anchor placement on posterior margin of articular surface, not on neck of glenoid. This allows for "capsulolabral reconstruction". See next image. Photo courtesy of Daniel C Wnorowski, MD.
After passage of anchor-based suture and completio After passage of anchor-based suture and completion of plication and "capsulolabral reconstruction," augmenting hypoplastic labrum with capsular fold. Note that these are permanent sutures and therefore are tied off glenoid to avoid knot-articular surface impingement. Photo courtesy of Daniel C Wnorowski, MD.
Previous
Next

Complications

General complications of instability repairs apply to any technique of MDI stabilization, whether open or arthroscopic. Failed repairs can result from a number of causes, including (but not limited to) the following:

  • Errors in diagnosis
  • Failure to address specific pathology (eg, omitting a Bankart repair in favor of a capsulorrhaphy when a labral detachment is present)
  • Loose repair
  • Problems with healing (including failure to recognize collagen diseases such as Ehlers-Danlos and Marfan syndromes)
  • Postoperative noncompliance
  • Reinjury

Norris[56] stressed that errors in diagnosis can include treating impingement as primary with decompression, missing secondary impingement caused by instability. This problem is especially common in throwers, swimmers, and other athletes who use overhead arm motions. A high index of suspicion for secondary impingement is required. Overtensioning the tighter side of a multidirectionally loose shoulder does not appear to be a common problem, but it is possible that a shift performed from the anterior side of a posterior predominant MDI pattern may worsen the posterior component, despite correcting the inferior component.

The inferior capsular laxity must be addressed in the MDI shoulder, and this has been discussed above. Failure to satisfactorily correct the inferior capsular laxity, failure to tighten the rotator-cuff interval, or failure to adequately support the shoulder postoperatively may lead to recurrent instability. Furthermore, for revision surgery after initial MDI surgery has failed, it is important to be sure that the interval has been repaired, that there are no labral detachments, and that the capsular flaps are firmly secured to the glenoid.

The axillary nerve is at particular risk during the inferior dissection and during development of the inferior flap in both anterior and posterior open approaches.[57] The relation of the nerve to the inferior capsule must also be kept in mind with use of arthroscopic thermal and suture techniques.

Some authors advocate exposure and isolation of the axillary nerve during this portion of the procedure. However, dissecting around the axillary nerve, merely to identify it, may paradoxically cause injury. It may be enough to maintain an elevator immediately beneath the inferior capsule while working on the inferior flap. (This author has not seen any axillary nerve injuries in hundreds of repairs, and has yet to make a specific effort to identify and isolate the nerve.)

In an excellent cadaveric study, Price et al[58] examined the relation of the axillary nerve to the inferior capsule as the nerve passes through the quadrangular space, in order to define the risk to this structure from an arthroscopic perspective, specifically in the axillary nerve's relationship to the glenoid rim and the inferior glenohumeral ligament (IGHL). The authors used a simulated lateral decubitus position, akin to typical arthroscopic positioning, with the arm in 5-lb traction, in 45° abduction and 20° flexion.

The following findings from this study are most relevant.[58] The axillary nerve branches from anterior to posterior. The branch to the teres minor was closest to the rim of the glenoid, and the branch to the anterior deltoid was the farthest, with the branch to the posterior deltoid and the superior lateral cutaneous branch both intermediate in position, the latter closer to the glenoid than the posterior deltoid motor branch.

The axillary nerve was closest to the glenoid rim at the 6 o'clock meridian, averaging a distance of 12.4 mm (11.6-13.2 mm at the 95% confidence interval [CI]) at this site.[58] At 10 mm anterior and posterior to the 6 o'clock meridian, the axillary nerve averaged a distance of 14.5 mm and 13.9 mm, respectively. Furthermore, the nerve was a mere 2.3 mm (1.7-2.9 mm at the 95% CI) from the IGHL at the 6 o'clock meridian, and averaged 2.8 mm at 10 mm anterior and posterior to the 6 o'clock meridian.

Limitations of this study were discussed by the authors.[58] They did not replicate capsular abnormalities that may be associated with unstable shoulders (ie, a loose capsule) or the effects of arthroscopic distention, both of which may alter the "normal" relations defined above. Clinical applications of this work may explain the predominance of sensory deficits with arthroscopic axillary nerve injury. The teres minor must be carefully evaluated because injury to the teres minor branch of the axillary nerve may be difficult to discern.

Significant axillary nerve risks and morbidity have been reported in both in-vivo and in-vitro studies of thermal procedures used to treat the inferior capsule.[59, 60, 61, 62, 63]

The relation of the axillary nerve to arthroscopically placed capsulolabral sutures was also studied by Eakin et al.[64] Ten cadaveric shoulders underwent suture placement that mimicked arthroscopic suture plication techniques. Sutures were placed in a simulated lateral decubitus position with the arm in 45° abduction and 20° flexion, with 10-lb traction, through the capsule 1 cm from the glenoid rim, and then through the labrum at anterior (3:00 or 9:00 o'clock), anteroinferior (4:30 or 7:30), posteroinferior (4:30 or 7:30), and posterior (3:00 or 9:00) positions.

The average distance of each suture position to the axillary nerve was 16.7 mm (13.7-19.7 mm at the 95% CI) for the anterior sutures, 12.5 mm (10.2-14.8) for the anteroinferior, 14.4 mm (10.9-17.9) for the inferior, 24.1 mm (19.7-28.5) for the posteroinferior, and 32.3 mm (28.4-36.4) for the posterior sutures.[64] The authors noted a statistically significant trend for the axillary nerve to lie closest to the anteroinferior sutures and then gradually at farther distances from more posteriorly placed sutures. They concluded that a "safe zone" exists between the common locations of suture placement for arthroscopic plication and the axillary nerve, but they urged caution during anteroinferior and inferior suture placement.[64]

Axillary nerve injuries are not unique to arthroscopic management of shoulder instability. Neer and Foster reported three cases of axillary neurapraxia in their landmark presentation of open inferior capsular shift.[14]

Before the abandonment of thermal capsulorrhaphy of the shoulder, complications were increasingly being reported. Weber[65] reported on 15 patients referred to his practice for complications related to this treatment method, including recurrent instability (11 patients), axillary nerve injury (three), adhesive capsulitis (two), and capsular necrosis (two). He advocated salvage of recurrent instability with revision open capsular shift.

Weber noted the transient nature of the axillary nerve injuries, but painful neuralgia persisted in two cases.[65] The stiff shoulders required subsequent capsular release but failed to gain complete motion at "final follow-up." Capsular necrosis is difficult to treat and may require autografting or allografting for salvage (Warner JP, personal communication, 2001). Weber stressed that these complications are serious but that true rates of complications are unknown and, therefore, the "RF technique" should be used with caution until more data are available.

Although there some successes were reported (Ceballos et al[45] reported high patient satisfaction, high return to preoperative activity levels (including athletes), and no neurologic problems), Karas et al[13] reported an overall failure rate of 26%; 50% of those failures occurred in individuals with posterior instability and 30% occurred in individuals with MDI.

D'Alessandro et al[18] and Hawkins et al[19] reported high failure rates, up to 60%, and a significant risk of chondrolysis and neurologic injury. Miniaci et al[66] noted a failure rate of 47% and reported four transient axillary nerve problems (three sensory and one motor, all resolving by 9 months) in 19 MDI patients followed for 2 years after monopolar thermal capsulorrhaphy. 

Wong and Williams[67] reported the results of a survey compiled by members of the American Shoulder and Elbow Surgeons, the Arthroscopy Association of North America, and the American Orthopaedic Society for Sports Medicine. The authors focused on recurrence of instability, axillary nerve injury, and the incidence of capsular necrosis following monopolar, bipolar, and laser thermal treatment for glenohumeral instability.

Thermal treatment was reported to be used in 14,277 (6%) of 236,015 cases, with most utilizing monopolar RF, where the rates of recurrent instability ranged from 7.1% and 8.4%.[67] Furthermore, between 18% and 33% of patients requiring revision surgery showed evidence of capsular attenuation (33% with laser treatment). The incidence of associated axillary nerve injury was 1.4% (least with laser), with 95% recovering between 2 and 4 months.

Proximal long head biceps tendon rupture has also been reported after thermal capsular capsulorrhaphy.[68, 69]

No axillary nerve injuries were reported in either of the suture plication series of Snyder[32, 12] and Wolf and Durkin.[11]

Previous
Next

Postoperative Rehabilitation

Neer and Foster recommended 6 weeks of postoperative immobilization, followed by heat and gentle assisted exercises.[28] Their goal was for the ROM to be 20° less than the opposite shoulder. They advocated that patients perform isometric exercises at 8 weeks postoperatively and progressive resistive exercises beginning at 12 weeks postoperatively. Additionally, Neer and Foster restricted sports and more than 20-lb lifting for 9 months and advised against swimming using back and butterfly strokes, heavy overhead use of the arm, and contact sports for 12 months after surgery.

Modern protocols for repair of traumatic instability are more aggressive, as the philosophy has shifted in parallel to knee rehabilitation; the focus is on obtaining complete ROM, with earlier institution of rotator-cuff strengthening in order to protect the surgical repair. Whether this opinion applies to the MDI-reconstructed shoulder may be debatable. This author has used the same protocol for both types of surgery.

According to Norris,[56] the most common complication of rehabilitation is recurrent instability caused by early motion and return to activity before complete healing. The opposite consideration, slow motion, is of at least equal concern because of the consequence of permanent motion loss and, if severe, iatrogenic arthritis similar to failed Magnuson-Stack and Putti-Platt procedures (incidence reported at 43%).[56]

Table 1 lists this author's current protocol for anterior capsular shift repairs. I delay both arthroscopically treated shoulders relative to a conventional open shift.

Table 1: Postoperative Multidirectional Instability (MDI) Rehabilitation Protocol (Open Table in a new window)

ANTERIOR CAPSULAR SHIFT (S-3)



Daniel Wnorowski MD



For open surgery, follow protocol as is!!!



For arthroscopic plication surgery, defer all events by two weeks!!!



Patient:_______________________________________



Date of Surgical Procedure:_______________________



Physical Therapist:______________________________



PHASE I - IMMOBILITY
  • Postoperative sling/immobilizer: Immobility ends on POW * 6
  • Active and passive ROM : Elbow and wrist allowed
  • Sling: Wear day/night through POW 3; night only POW 4-5
  • Immobilizer: Wear all times except shower/bath through POW 5
PHASE II - MOTION



  • Begin ROM on POW 2 (start supine): Start with Codman pendulum exercises, followed by wand exercises as tolerated.
  • ROM (active and passive)
  • Flexion/internal rotation: Increase as tolerated starting POW 2.
  • External rotation: To neutral external rotation ASAP ("shooter position"), then increase 10°/wk
  • Abduction: To 45° abduction ASAP, then increase 10°/wk
*** After 6 weeks, increase all ranges as tolerated.***



PHASE III - ISOMETRIC
  • Isometrics: All muscles; can use spectrum isometrics, except subscapularis muscle restricted through POW 3
  • Neuromuscular stimulator optional
PHASE IV - ISOTONIC



  • Start PREs on POW 5; begin supine position; progress to standing as tolerated (hand weights or stretch cords).
  • Rotator cuff program: Avoid impingement positions early; elbow and wrist PREs as tolerated
***These are all individualized, as tolerated; progress from submaximal midrange isometrics to short arc isotonics.***



PHASE V - ISOKINETIC
  • Begin with concentrics.
  • Can start on POW 10
  • Body position: Sitting or standing
  • High speed: ROM restrictions - Plane of scapula, external rotation 30° body adduction/no abduction
  • Low speed: ROM restrictions - Plane of scapula, external rotation 30° body adduction/no abduction
  • Eccentric work and PNF § program at 12-14 weeks
PHASE VI - ENDURANCE
  • May start swimming on POW 12-16. (Restrictions: Do not perform overhead strokes until POW 16.)
  • Start short toss program POW 12.
  • Restrictions:_________________________________________________.
PHASE VII - SPORTS
  • Begin participation on POW 24 (for contact/collision and throwing sports).
  • Restrictions: Must have strength test and authorization from physician prior to return to activity
  • Lifting activities restricted to 10-15 lb for 2 months; then increase as tolerated.
  • Delay return to activity (sports) until after 4 months and with physician clearance.
  • Full-functional activities (except lifting and sports); ADLs || permitted at 8 weeks postsurgery
* POW - Postoperative week



ROM - Range of motion



PREs - Progressive-resistive exercises



§ PNF - Proprioceptive neuromuscular facilitation



|| ADLs - Activities of daily living



Previous
 
Contributor Information and Disclosures
Author

Daniel C Wnorowski, MD, MBA Consulting Surgeon, Department of Orthopedic Surgery, Syracuse Orthopedic Specialists, PC

Daniel C Wnorowski, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Eastern Orthopaedic Association, Wilderness Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

S Ashfaq Hasan, MD Associate Professor, Chief, Shoulder and Elbow Service, Department of Orthopaedics, University of Maryland School of Medicine

S Ashfaq Hasan, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Shoulder and Elbow Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Cato T Laurencin, MD, PhD University Professor, Albert and Wilda Van Dusen Endowed Distinguished Professor of Orthopedic Surgery, and Professor of Chemical, Materials, and Biomolecular Engineering, University of Connecticut School of Medicine

Cato T Laurencin, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

References
  1. Castagna A, Nordenson U, Garofalo R, Karlsson J. Minor shoulder instability. Arthroscopy. 2007 Feb. 23(2):211-5. [Medline].

  2. Perthes G. Uber Operationen bei Habitueller Schulterluxation. Deutsch Ztschr Chir. 1906. 85:199-227.

  3. Bankart ASB. Recurrent or habitual dislocation of the shoulder joint. Br Med J. 1923. 2:1132-3.

  4. Matsen FA III, Lippitt SB, Sidles JA, Harryman DT II, eds. Practical Evaluation and Management of the Shoulder. Philadelphia, Pa: WB Saunders. 1994:60-81.

  5. O'Connell PW, Nuber GW, Mileski RA, Lautenschlager E. The contribution of the glenohumeral ligaments to anterior stability of the shoulder joint. Am J Sports Med. 1990 Nov-Dec. 18(6):579-84. [Medline].

  6. Ovesen J, Nielsen S. Anterior and posterior shoulder instability. A cadaver study. Acta Orthop Scand. 1986 Aug. 57(4):324-7. [Medline].

  7. Turkel SJ, Panio MW, Marshall JL, Girgis FG. Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint. J Bone Joint Surg Am. 1981 Oct. 63(8):1208-17. [Medline].

  8. Kirkley A, Adlington J, Edmonds G, Griffin S. Proprioception in multi-directional instability (paper #27). Presented at: 68th Annual Meeting of the American Academy of Orthopaedic Surgeon. February 28 - March 4, 2001. San Francisco, Calif.

  9. Hawkins RJ, Bokor DJ. Clinical evaluation of shoulder problems. In: Rockwood CA, Matsen FA, eds. The Shoulder. 2nd ed. Philadelphia, Pa: WB Saunders. 1990:151.

  10. Matsen FA III, Thomas SC, Rockwood CA. Glenohumeral instability. In: Rockwood CA, Matsen FA, eds. The Shoulder. 2nd ed. Philadelphia, Pa: WB Saunders. 1990:600.

  11. Wolf EM, Durkin R. Arthroscopic capsular plication for multidirectional instability. Arthroscopy. 1999. 15(5):572-3.

  12. Snyder SJ. Arthroscopic capsular plication for "non-Bankart" shoulder instability. Presented at: 19th Annual Meeting of the Arthroscopy Association of North. America; April 13-16, 2001. Miami Beach, Fla.

  13. Karas SG, Noonan TJ, Horan M, Hawkins RJ. Outcomes of shoulder instability treated with radiofrequency thermal capsulorrhaphy. Presented at: 19th Annual Meeting of the Arthroscopy Association of. North America; April 13-16, 2001. Miami Beach, Fla.

  14. Neer CS, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am. 1980 Sep. 62(6):897-908. [Medline].

  15. Marberry TA. Experience with the Neer inferior capsular shift for multidirectional instability. Orthop Trans. 1988. 15:747.

  16. Lebar RD, Alexander AH. Multidirectional shoulder instability. Clinical results of inferior capsular shift in an active-duty population. Am J Sports Med. 1992 Mar-Apr. 20(2):193-8. [Medline].

  17. Treacy SH, Field LD, Savoie FH. Arthroscopic inferior capsular shift for multidirectional instability of the shoulder. Arthroscopy. 1997 Jun. 13(3):377-8.

  18. D'Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: indications and results, two- to five-year follow-up. Am J Sports Med. 2004 Jan-Feb. 32(1):21-33. [Medline].

  19. Hawkins RJ, Krishnan SG, Karas SG, Noonan TJ, Horan MP. Electrothermal arthroscopic shoulder capsulorrhaphy: a minimum 2-year follow-up. Am J Sports Med. 2007 Sep. 35(9):1484-8. [Medline].

  20. Illyés A, Kiss RM. Electromyographic analysis in patients with multidirectional shoulder instability during pull, forward punch, elevation and overhead throw. Knee Surg Sports Traumatol Arthrosc. 2007 May. 15(5):624-31. [Medline].

  21. Owens BD, Duffey ML, Nelson BJ, DeBerardino TM, Taylor DC, Mountcastle SB. The incidence and characteristics of shoulder instability at the United States Military Academy. Am J Sports Med. 2007 Jul. 35(7):1168-73. [Medline].

  22. Tibone JE, Elrod B, Jobe FW, et al. Surgical treatment of tears of the rotator cuff in athletes. J Bone Joint Surg Am. 1986 Jul. 68(6):887-91. [Medline].

  23. Zlatkin MB. In: Zlatkin MB, Iannotti JP, Schnall MD, eds. MRI of the Shoulder. New York, NY: Raven Press. 1991:123-4.

  24. Flannigan B, Kursunoglu-Brahme S, Snyder S, et al. MR arthrography of the shoulder: comparison with conventional MR imaging. AJR Am J Roentgenol. 1990 Oct. 155(4):829-32. [Medline].

  25. Schaeffeler C, Waldt S, Bauer JS, Kirchhoff C, Haller B, Schröder M, et al. MR arthrography including abduction and external rotation images in the assessment of atraumatic multidirectional instability of the shoulder. Eur Radiol. 2014 Jun. 24(6):1376-85. [Medline].

  26. Castagna A, Snyder SJ, Conti M, Borroni M, Massazza G, Garofalo R. Posterior humeral avulsion of the glenohumeral ligament: a clinical review of 9 cases. Arthroscopy. 2007 Aug. 23(8):809-15. [Medline].

  27. Wang V, Pawluk RJ, Levine WN. Comparison of glenohumeral mechanics following a capsular shift and anterior tightening (paper #31). Presented at: The American Academy of Orthopaedic. Surgeons. February 28 - March 4; San Francisco, Calif.

  28. Neer CS II, Foster CR. Involuntary inferior and multidirectional instability of the shoulder: etiology, recognition, and treatment. Instr Course Lect. 1985. 34:232-8.

  29. Brems JJ, Bergfeld J. Multidirectional shoulder instability. Orthop Trans. 1991. 15:84.

  30. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am. 1991 Jan. 73(1):105-12. [Medline].

  31. Bigliani LU, Kurzweil PR, Schwartzbach CC, et al. Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med. 1994 Sep-Oct. 22(5):578-84. [Medline].

  32. Snyder SJ. Shoulder Arthroscopy. New York, NY: McGraw-Hill;. 1994:191-2.

  33. Wiater JM, Vibert BT. Glenohumeral joint volume reduction with progressive release and shifting of the inferior shoulder capsule. J Shoulder Elbow Surg. 2007 Nov-Dec. 16(6):810-4. [Medline].

  34. Hayashi K, Thabit G, Bogdanske JJ. The effect of nonablative laser energy on the ultrastructure of joint capsular collagen. Arthroscopy. 1996 Aug. 12(4):474-81. [Medline].

  35. Friedman RJ. Glenohumeral capsulorrhaphy. In: Matsen FA, Fu FH, Hawkins RJ, eds. The Shoulder: A Balance of Mobility. Rosemont, Ill: American Academy of Orthopaedic Surgeons. 1993:452.

  36. Edwards RB, Hayashi K, Lu Y, Markel MD. Re: "The acute effects of radiofrequency energy in articular cartilage: an in vitro study" by Kaplan et al. Arthroscopy. 2000 Nov. 16(8):877-8. [Medline].

  37. Lu Y, Hayashi K, Hecht P, et al. The effect of monopolar radiofrequency energy on partial-thickness defects of articular cartilage. Arthroscopy. 2000 Jul-Aug. 16(5):527-36. [Medline].

  38. West H, West J, Lowe B. Bipolar vs monopolar: the effect of electrode configuration on thermal penetration in collagenous tissue. Presented at: The American Orthopaedic Society for. Sports Medicine Specialty Day. March 3, 2001; San Francisco, Calif.

  39. Hayashi K, Markel MD, Thabit G III, et al. The effect of nonablative laser energy on joint capsular properties. An in vitro mechanical study using a rabbit model. Am J Sports Med. 1995 Jul-Aug. 23(4):482-7. [Medline].

  40. Lopez MJ, Hayashi K, Fanton GS, et al. The effect of radiofrequency energy on the ultrastructure of joint capsular collagen. Arthroscopy. 1998 Jul-Aug. 14(5):495-501. [Medline].

  41. Naseef GS, Foster TE, Trauner K, et al. The thermal properties of bovine joint capsule. The basic science of laser- and radiofrequency-induced capsular shrinkage. Am J Sports Med. 1997 Sep-Oct. 25(5):670-4. [Medline].

  42. Hecht P, Hayashi K, Cooley AJ, et al. The thermal effect of monopolar radiofrequency energy on the properties of joint capsule. An in vivo histologic study using a sheep model. Am J Sports Med. 1998 Nov-Dec. 26(6):808-14. [Medline].

  43. Lu Y, Hayashi K, Edwards RB III, et al. The effect of monopolar radiofrequency treatment pattern on joint capsular healing. In vitro and in vivo studies using an ovine model. Am J Sports Med. 2000 Sep-Oct. 28(5):711-9. [Medline].

  44. Hecht P, Hayashi K, Lu Y, et al. 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. Am J Sports Med. 1999 Nov-Dec. 27(6):761-71. [Medline].

  45. Ceballos C, Zvijac JE, Uribe JW, Hechtman KS. Arthroscopic thermal capsulorrhaphy in multidirectional glenohumeral instability. Paper presented at: 19th Annual Meeting of the Arthroscopy Association of. North America. April 13-16, 2000; Miami Beach, Fla.

  46. Shafer BL, Mihata T, McGarry MH, Tibone JE, Lee TQ. Effects of capsular plication and rotator interval closure in simulated multidirectional shoulder instability. J Bone Joint Surg Am. 2008 Jan. 90(1):136-44. [Medline].

  47. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of multidirectional glenohumeral instability: 2- to 5-year follow-up. Arthroscopy. 2001 Mar. 17(3):236-243. [Medline].

  48. Baker CL 3rd, Mascarenhas R, Kline AJ, Chhabra A, Pombo MW, Bradley JP. Arthroscopic treatment of multidirectional shoulder instability in athletes: a retrospective analysis of 2- to 5-year clinical outcomes. Am J Sports Med. 2009 Sep. 37(9):1712-20. [Medline].

  49. Caprise PA Jr, Sekiya JK. Open and arthroscopic treatment of multidirectional instability of the shoulder. Arthroscopy. 2006 Oct. 22(10):1126-31. [Medline].

  50. Gerber C, Werner CM, Macy JC, et al. Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint Surg Am. 2003 Jan. 85-A(1):48-55. [Medline].

  51. Alberta FG, Elattrache NS, Mihata T, et al. Arthroscopic anteroinferior suture plication resulting in decreased glenohumeral translation and external rotation. Study of a cadaver model. J Bone Joint Surg Am. 2006 Jan. 88(1):179-87. [Medline].

  52. Flanigan DC, Forsythe T, Orwin J, Kaplan L. Volume analysis of arthroscopic capsular shift. Arthroscopy. 2006 May. 22(5):528-33. [Medline].

  53. Sekiya JK, Willobee JA, Miller MD, Hickman AJ, Willobee A. Arthroscopic multi-pleated capsular plication compared with open inferior capsular shift for reduction of shoulder volume in a cadaveric model. Arthroscopy. 2007. 23(11):1145-1151. [Medline].

  54. Provencher MT, Mologne TS, Hongo M, Zhao K, Tasto JP, An KN. Arthroscopic versus open rotator interval closure: biomechanical evaluation of stability and motion. Arthroscopy. 2007 Jun. 23(6):583-92. [Medline].

  55. Plausinis D, Bravman JT, Heywood C, Kummer FJ, Kwon YW, Jazrawi LM. Arthroscopic rotator interval closure: effect of sutures on glenohumeral motion and anterior-posterior translation. Am J Sports Med. 2006 Oct. 34(10):1656-61. [Medline].

  56. Norris TR. Complications following anterior instability repairs. In: Bigliani LU, ed. Complications of Shoulder Surgery. Baltimore, Md: Lippincott Williams & Wilkins. 1993:98-116.

  57. Loomer R, Graham B. Anatomy of the axillary nerve and its relation to inferior capsular shift. Clin Orthop Relat Res. 1989 Jun. 100-5. [Medline].

  58. Price MR, Tillett ED, Acland RD, Nettleton GS. Determining the relationship of the axillary nerve to the shoulder joint capsule from an arthroscopic perspective. J Bone Joint Surg Am. 2004 Oct. 86-A(10):2135-42. [Medline].

  59. Esmail AN, Getz CL, Schwartz DM, et al. Axillary nerve monitoring during arthroscopic shoulder stabilization. Arthroscopy. 2005 Jun. 21(6):665-71. [Medline].

  60. Gryler EC, Greis PE, Burks RT, West J. Axillary nerve temperatures during radiofrequency capsulorrhaphy of the shoulder. Arthroscopy. 2001 Jul. 17(6):567-72. [Medline].

  61. Monafo WW, Eliasson SG. Sciatic nerve function following hindlimb thermal injury. J Surg Res. 1987 Oct. 43(4):344-50. [Medline].

  62. Langberg JJ, Calkins H, el-Atassi R, et al. Temperature monitoring during radiofrequency catheter ablation of accessory pathways. Circulation. 1992 Nov. 86(5):1469-74. [Medline].

  63. Wen ZC, Chen SA, Chiang CE, et al. Temperature and impedance monitoring during radiofrequency catheter ablation of slow AV node pathway in patients with atrioventricular node reentrant tachycardia. Int J Cardiol. 1996 Dec 13. 57(3):257-63. [Medline].

  64. Eakin CL, Dvirnak P, Miller CM, Hawkins RJ. The relationship of the axillary nerve to arthroscopically placed capsulolabral sutures. An anatomic study. Am J Sports Med. 1998 Jul-Aug. 26(4):505-9. [Medline].

  65. Weber S. Complications associated with thermal capsulorrhaphy of the shoulder. Presented at: The American Orthopaedic Society for. Sports Medicine Specialty Day. March 3, 2001; San Francisco, Calif.

  66. Miniaci A, McBirnie J, Miniaci SL. Thermal capsulorrhaphy for the treatment of multi-directional instability of the shoulder (paper #202). Presented at: 68th Annual Meeting of the American Academy of Orthopaedic. Surgeons February 28 - March 4, 2001; San Francisco, Calif.

  67. Wong KL, Williams GR. Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am. 2001. 83-A Suppl 2 Pt 2:151-5. [Medline].

  68. Hanypsiak BT, Faulks C, Fine K, et al. Rupture of the biceps tendon after arthroscopic thermal capsulorrhaphy. Arthroscopy. 2004 Jul. 20 (suppl 2):77-9. [Medline].

  69. Johnson O, Walker D. Three cases of biceps tendon rupture following thermal capsulorrhaphy in the shoulder. Surg Physician Assistant. 2001. 7:12-7.

 
Previous
Next
 
Labral features characteristic of multidirectional instability; normal appearing. Note: Although there is only 2 lb of traction, it is very easy to push arthroscope between humeral head and glenoid surfaces (ie, drive-through sign). Photo courtesy of Daniel C Wnorowski, MD.
Hypoplastic labrum. Photo courtesy of Daniel C Wnorowski, MD.
Posterior and superior aspects of humeral head of shoulder with multidirectional instability are pristine. Typically, there is no Hill-Sachs lesion, even if there has been subluxation. Photo courtesy of Daniel C Wnorowski, MD.
Posterior aspect of humeral head of shoulder with multidirectional instability is without Hill-Sachs lesion. Also note patulous capsule. Photo courtesy of Daniel C Wnorowski, MD.
Multidirectional instability of right shoulder, from posterior portal. Patient is in lateral position with minimal arm traction (2 lb). Note glenohumeral inferior subluxation, with humeral head perched on normal-appearing anterior-inferior labrum. Photo courtesy of Daniel C Wnorowski, MD.
Normal subacromial space in patient with multidirectional instability and history of secondary impingement. Photo courtesy of Daniel C Wnorowski, MD.
Cosmetically ideal modified axillary incision for open inferior capsular shift. Incision will be made in apex of axillary crease. Photo courtesy of Daniel C Wnorowski, MD.
Open approach via axillary incision. Self-retaining retractor is shifted cephalad after mobilization of skin flaps. Photo courtesy of Daniel C Wnorowski, MD.
Rotator-cuff interval is closed with nonabsorbable suture. T-capsulotomy incision is planned with dotted lines.
Superomedial (SM) and inferomedial (IM) flaps created by T-capsulotomy incision. First, IM flap will be advanced superiorly and laterally; then, SM flap will be advanced inferiorly over top of IM flap.
Finished repair with superomedial (SM) flap advanced inferiorly, overlapping previous inferomedial (IM) flap advancement. Note how axillary pouch has been eliminated.
Suture passer device (Spectrum; ConMed Linvatec, Largo, FL) is placed through working cannula, then through "pinch" of posterior capsule, and also through posterior labrum. Photo courtesy of Daniel C Wnorowski, MD.
Next, with monofilament suture and all-arthroscopic knot-tying technique, knot is tied, thus plicating capsular "pinch" to labrum. Photo courtesy of Daniel C Wnorowski, MD.
Process in image above is repeated to place second, slightly more superior suture and knot. Photo courtesy of Daniel C Wnorowski, MD.
Close-up of third "pinch." Photo courtesy of Daniel C Wnorowski, MD.
Close-up of third labral pass. Photo courtesy of Daniel C Wnorowski, MD.
Third suture is placed. Photo courtesy of Daniel C Wnorowski, MD.
Completed third knot. Photo courtesy of Daniel C Wnorowski, MD.
Depending on degree of capsular laxity, one may take "double tuck" to achieve additional plication and tightening, at risk of added range of motion restriction. Photo courtesy of Daniel C Wnorowski, MD.
View from posterior portal of "interval closure"; with suture passer device, monofilament suture is placed at margins of cuff interval. Photo courtesy of Daniel C Wnorowski, MD.
Knot is tied through anterosuperior portal, thus closing rotator-cuff interval. Photo courtesy of Daniel C Wnorowski, MD.
Second of two anchors placed for posterior plication, given hypoplastic posterior labrum, prior to suture passage. Note anchor placement on posterior margin of articular surface, not on neck of glenoid. This allows for "capsulolabral reconstruction". See next image. Photo courtesy of Daniel C Wnorowski, MD.
After passage of anchor-based suture and completion of plication and "capsulolabral reconstruction," augmenting hypoplastic labrum with capsular fold. Note that these are permanent sutures and therefore are tied off glenoid to avoid knot-articular surface impingement. Photo courtesy of Daniel C Wnorowski, MD.
Monopolar radiofrequency probe applied to posterior capsule with grid technique after treatment to 65°C. Ellipses indicate areas of linear application (grid lines). Rectangle indicates untreated island between lines. Photo courtesy of Daniel C Wnorowski, MD.
Table 1: Postoperative Multidirectional Instability (MDI) Rehabilitation Protocol
ANTERIOR CAPSULAR SHIFT (S-3)



Daniel Wnorowski MD



For open surgery, follow protocol as is!!!



For arthroscopic plication surgery, defer all events by two weeks!!!



Patient:_______________________________________



Date of Surgical Procedure:_______________________



Physical Therapist:______________________________



PHASE I - IMMOBILITY
  • Postoperative sling/immobilizer: Immobility ends on POW * 6
  • Active and passive ROM : Elbow and wrist allowed
  • Sling: Wear day/night through POW 3; night only POW 4-5
  • Immobilizer: Wear all times except shower/bath through POW 5
PHASE II - MOTION



  • Begin ROM on POW 2 (start supine): Start with Codman pendulum exercises, followed by wand exercises as tolerated.
  • ROM (active and passive)
  • Flexion/internal rotation: Increase as tolerated starting POW 2.
  • External rotation: To neutral external rotation ASAP ("shooter position"), then increase 10°/wk
  • Abduction: To 45° abduction ASAP, then increase 10°/wk
*** After 6 weeks, increase all ranges as tolerated.***



PHASE III - ISOMETRIC
  • Isometrics: All muscles; can use spectrum isometrics, except subscapularis muscle restricted through POW 3
  • Neuromuscular stimulator optional
PHASE IV - ISOTONIC



  • Start PREs on POW 5; begin supine position; progress to standing as tolerated (hand weights or stretch cords).
  • Rotator cuff program: Avoid impingement positions early; elbow and wrist PREs as tolerated
***These are all individualized, as tolerated; progress from submaximal midrange isometrics to short arc isotonics.***



PHASE V - ISOKINETIC
  • Begin with concentrics.
  • Can start on POW 10
  • Body position: Sitting or standing
  • High speed: ROM restrictions - Plane of scapula, external rotation 30° body adduction/no abduction
  • Low speed: ROM restrictions - Plane of scapula, external rotation 30° body adduction/no abduction
  • Eccentric work and PNF § program at 12-14 weeks
PHASE VI - ENDURANCE
  • May start swimming on POW 12-16. (Restrictions: Do not perform overhead strokes until POW 16.)
  • Start short toss program POW 12.
  • Restrictions:_________________________________________________.
PHASE VII - SPORTS
  • Begin participation on POW 24 (for contact/collision and throwing sports).
  • Restrictions: Must have strength test and authorization from physician prior to return to activity
  • Lifting activities restricted to 10-15 lb for 2 months; then increase as tolerated.
  • Delay return to activity (sports) until after 4 months and with physician clearance.
  • Full-functional activities (except lifting and sports); ADLs || permitted at 8 weeks postsurgery
* POW - Postoperative week



ROM - Range of motion



PREs - Progressive-resistive exercises



§ PNF - Proprioceptive neuromuscular facilitation



|| ADLs - Activities of daily living



Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.