- Email: [email protected]
Arthroscopic capsular plication formultidirectional instability of the shoulder
ARTHROSCOPIC CAPSULAR PLICATION FOR MULTIDIRECTIONAL INSTABILITY OF THE SHOULDER MARK T. WICHMAN, MD, and STEPHEN J. SNYDER, MD
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. KEY WORDS: multidirectional instability, capsular plication
The initial study of multidirectional instability (MDI) was that of Neer and Foster's classic article in 1980.1 The technique of both the anterior and posterior approaches to the inferior capsular shift procedure were elucidated in this work. In Neer's study, 11 of 40 shoulders had previous surgery. The most common mistaken diagnoses in this group were: unidirectional dislocation, voluntary dislocation, impingement, biceps tendinitis, rotator cuff tear, and glenoid deficiency. In 1992, Cooper and Brems 2 reported their experience with the inferior capsular shift from an anterior approach. Almost half of their patients had previous surgery, mostly consisting of stabilization procedures. Bigliani et al 3 published work on the inferior capsular shift procedure for anterior-inferior instability in athletes. Roughly one quarter of these patients had undergone at least one previous surgical procedure. All of these investigators repaired antero-inferior capsulolabral avulsion (Bankart lesions) with drill holes and sutures when they were identified. The capsular shift was performed after the Bankart repair in these cases. Results of the inferior capsular shift are good. Unfortunately, no two investigators have used the same shoulder scoring criteria in studying MDI. Although only 17 of Neer's 40 shoulders were followed up for 2 years, there were 16 satisfactory and only one unsatisfactory result. In Cooper's studN 91% had no symptomatic instability after 2 years. However, the investigators state that of the athletes in their group, only half were able to return to the same sport. Of those that returned to their sport, some had returned at a lower level of participation. In addition, 21% had weekly or monthly episodes of apprehension. Bigliani had 96% good or excellent results in his series of athletes. Ninety-four percent returned to the same sport, and 75% From the Milwaukee Orthopedic Specialists, Milwaukee, Wl; and the Southern California Orthopedic Institute, Van Nuys, CA. Address reprint requests to MarkT. Wichman, MD, Milwaukee Orthopedic Specialists, 1575 N. RiverCenter Dr, Suite 160, Milwaukee, WI 53212. Copyright © 1997 by W.B. Saunders Company 1060-1872/97/0504-000655.00/0
238
returned to the same competitive level of athletics. Thirtyone percent of the athletic patients in this series had a Bankart lesion identified at surgery that was repaired along with the capsular shift. Complications of inferior capsular shift are not common. Neer noted three cases of axillary nerve neuropraxia, but there were none identified in the other studies. Two other open procedures described for MDI of the shoulder are that of Jobe, and that of Altchek and Warren. Jobe 4 has reported the results of the anterior capsulolabral reconstruction. In this procedure, the subscapularis is split in line with its fibers and the capsule is then shifted on the glenoid side. The inferior leaflet of capsule is sewn on the articular side of the labrum, while the superior leaflet is imbricated over this. This creates a "bumper" effect, according to the Jobe. Of the 25 overhand throwing athletes, 68% returned to at least one season at the previous level of competition. Overall 96% were satisfied with their procedure. Altchek and Warren's 4 series consisted of a retrospective review of patients who had undergone a Bankart procedure and also had an additional procedure for MDI. Most of these patients had actual traumatic dislocations and 90% had Bankart lesions. After repair of the Bankart lesion, the capsule is shifted in a similar fashion to Neer's procedure, except it is performed on the glenoid side. Ninety-five percent good or excellent results are reported with the combined procedure. The arthroscopic literature on treatment of MDI is even more scant. In 1993, Duncan and Savoie 5 published a preliminary report of an arthroscopic technique for inferior capsular shift for MDI. It represented the first study in our search of the literature reporting results from an arthroscopic capsular shift. The procedure includes the division of the anterior and inferior capsule with an end-cutting shaver. The capsule is advanced superiorly including a "key stitch" in the posterior inferior ligament. A transglenoid suture technique is used. Ten consecutive patients were evaluated i to 3 years postoperatively. Nine of 10 had previous dislocations. Four had Bankart lesions found
Operative Techniques in Sports Medicine, Vol 5, No 4 (October), 1997: pp 238-243
during arthroscopy. The Bankart score and Neer system of shoulder grading were used. The average Bankart score was 90, and all 10 patients had a "satisfactory" shoulder according to the satisfactory/unsatisfactory criteria of Neer. There are several surgical principles taken from the above review of the literature on the surgical management of MDI. First, it seems that success may be achieved with capsular shift on either the glenoid or humeral side of the shoulder joint. Each has its own theoretical advantages. Second, the surgical approach must enable the surgeon to readily visualize a Bankart lesion and repair it. This would include recognition of the more uncommon posterior capsulolabral avulsion. Third, the procedure must allow the surgeon to balance the capsular shift anteriorly, inferior, and posteriorly, if necessary. Fourth, one must either leave the subscapularis undisturbed or repair it in an anatomic position if one expects to regain optimal motion. Fifth, the arm must be maintained in a "safe" position during the capsular shift to avoid overtightening of the capsule, which could happen with the arm down at the patient's side. Additionally, it seems beneficial to be able to create a bumper type of effect by thickening or widening the labrum. Optimally, one would use the same suture material used during an open procedure. Lastly, the procedure must have an excellent margin of safety with few complications. This text presents the Southern California Orthopedic Institute's (SCOI) procedure for MDI.
INDICATIONS The technique of arthroscopic capsular plication of the shoulder may be applied to isolated anterior, isolated posterior, or MDI. Our current surgical indications are for those patients with functional impairment of the shoulder secondary to MDI. These patients commonly have a positive sulcus sign combined with anterior or posterior instability. Often these patients have a history of either minor trauma or repetitive overuse. Swimmers and overhand athletes with this problem are often misdiagnosed with subacromial pathology. Patients with documented dislocations or evidence of traumatic dislocation such as a Hill-Sachs lesion, a Bankart lesion found on magnetic resonance imaging, or a fracture of the inferior margin of the glenoid are generally scheduled for a stabilization procedure. At the time of surgery, the amount of capsular redundancy dictates the amount of plication that can be included with their primary repair. The role of rehabilitation as the mainstay of treatment for MDI is not to be underestimated. A prolonged course of rotator cuff strengthening as well as deltoid and scapular stabilization programs are initiated. If the patient is referred after a rehabilitation program elsewhere, we urge them to undergo more therapy under our supervision. This allows for serial examinations over many weeks, improving our knowledge of the patient and the disorder. This may also allow identification of patients with voluntary subluxation or those with secondary gain.
PREOPERATIVE EVALUATION The physical examination of the shoulder is beyond the scope of this article. Some key areas of the preoperative ARTHROSCOPIG CAPSULAR PLICATION FOR MDI
examination are mentioned. We recommend following a standardized worksheet while performing the examination to avoid neglecting aspects of the examination due to forgetfulness, distractions, etc. We prefer to inspect, palpate, check range of motion, perform manual muscle testing and provocative tests of rotator cuff and biceps musculature while the patient is sitting. We also perform gross evaluation of the cervical spine, neurovascular status, degree of inferior laxity (sulcus sign), and check for signs of generalized ligamentous laxity in the sitting position. The next portion of the examination is performed with the patient supine. Range of motion is again assessed with the shoulder abducted 90 ° . Apprehension and apprehension/suppression (ie, relocation test) are noted. We complete the examination with the patient in the lateral position for subluxation testing. Often the normal side will be evaluated first, followed by the symptomatic shoulder. Radiographs are also reviewed. We routinely obtain an anteroposterior view in the plane of the scapula and an axillary lateral. Outlet views and Zanca views of the acromioclavicular (AC) joint are only obtained on an individualized basis in patients with suspected MDI. Often the patients bring in a previous MRI scan, but we do not routinely order MRIs on such patients.
OPERATIVE TECHNIQUE A general anesthetic is administered with or without an interscalene block. An examination under anesthesia is performed and compared to the opposite extremity, especially if there is any uncertainty of the degree or direction of instability. The patient is positioned in the lateral decubitus position on a bean bag. The shoulder is reexamined in the lateral position, then prepared and draped as usual. We prefer to record the preoperative examination under anesthesia on the operative videotape. A separate video camera is uncoupled from the arthroscopy equipment and held a few feet from the patient by the assistant. When this is complete, the shoulder and entire upper extremity is prepared in a sterile fashion. The arm is placed in approximately 70 ° of abduction and roughly 10 lbs of support is applied. We use a three-point shoulder positioning device and foam padded sleeve (STAR Sleeve, Arthrex, Inc, Naples, FL).
DiagnosticArthroscopy A routine videorecorded diagnostic arthroscopy is performed. Visualization begins from the posterior portal. This portal is made 2 to 3 cm inferior and 1 to 2 cm medial to the posterolateral corner of the acromion. The portal is made slightly more superior when posterior plication is anticipated to allow more access to the posterior inferior glenohumeral ligament. The anterior superior (AS) portal is made next. One deviation from our standard technique is the more superior placement of the anterior portal. During instability surgery, this portal is made using an outside-in technique (as opposed to the Wissinger rod technique) with needle localization before making the anterior incision. This allows room inferiorly for the anterior midglenoid (AMG) portal to be made later. These two anterior portals must share the rotator interval. Instrumentation is facilitated by maximizing the skin bridge
239
between them. Once the posterior superior (PS) and AS portals are established, the complete 15-point arthroscopic examination, as described by SJS, 6 is performed. C o m m o n Arthroscopic Findings
In our series, we noted that 16 of 24 patients had fraying of the posterior labrum. Most typical was fraying of the posterior inferior labrum, although two of these patients had flap tears of the posterior labrum. A second classic finding is a patulous posterior capsule and often atrophic superior band of the anterior inferior glenohumeral ligament. Additionally, patients often had anteroinferior subluxation of the shoulder with minimal weight in the arm support apparatus. Other findings, such as superior labruin anterior posterior lesions and partial thickness rotator cuff tears, were not uncommon. A bursoscopy is performed for cases in which articular side rotator cuff pathology is noted during surgery, or if there is preoperative suggestion of bursal-side rotator cuff pathology such as fluid in the bursa on MRI. This is performed when the stabilization is complete. C a p s u l a r Plication
After completing the diagnostic examination and treatment for associated intra-articular pathology, the capsular plication is performed as follows. An anterior midglenoid portal is developed using an outside-in technique. This portal is made approximately 3 cm distal and 2 cm lateral to the AS portal. Again, it is desirable to have as wide a skin bridge between these two portals as possible to facilitate instrumentation. A translucent 8.4-ram screw-in cannula is advanced using a blunt obturator through the anterior soft tissue structures to pierce the anterior capsule just superior to the subscapularis tendon. This cannula allows passage of large suture hooks in the plication procedure. If the surgeon begins with anterior plication, the arthroscope is placed in the PS portal, and a manual synovial rasp or 4.5-mm turbo whisker is used to excoriate the synovium overlying the anterior and inferior capsule and along the edge of the capsular side of the labrum. This should cause the small capillaries to bleed and promote healing of these two opposing surfaces (Fig 1). A 90 ° suture hook (Linvatec Corporation, Largo, FL) loaded with a suture Shuttle Relay is used through the AMG portal and a pinch stitch is created in the anteroinferior capsule (Fig 2). The needle is advanced superior and medially passed through the antero-inferior labrum, creating a 1-cm fold between the capsule and the labrum. The Shuttle Relay is advanced through the suture hook and retrieved through the AS portal with an arthroscopic grasper (Fig 3). A #2 Ethibond suture is loaded in the eyelet of the Shuttle Relay that transports the suture material back through the labruin, capsule, and AMG portal (Fig 4). A second pinch stitch is created i cm from and parallel to the first, and the Shuttle Relay is advanced and retrieved with a grasper. The opposite end of the original suture is loaded into the eyelet of the Shuttle Relay and passed through the tissue. A horizontal mattress suture has now been placed, creating a 1-cm fold between the capsule and the labrum (Fig 5). The two free ends of suture are tied with a loop-handled knot pusher, closing the prepared sides of capsule together with
240
Fig 1. A small rasp is used to excoriate the synovium.
Fig 2. A pinch stitch is created with a 90 ° suture hook. WlCHMAN AND SNYDER
Fig 3. The pinch is advanced superiorly and medially, creating a 1-cm fold between the capsule and labrum. The suture Shuttle Relay is advanced through the needle and retrieved out the AS portal.
Fig 4. The Shuttle Relay loaded with #2 Ethibond is pulled back through the labrum and the capsular pinch, and out the anterior mid glenoid portal.
the knot away from the articular surface (Fig 6). Sutures placed posteriorly are often done with a crescent shaped suture hook from the posterior portal while visualizing from the AS portal (Fig 7). Additional sutures are placed anteriorly; inferiorly, or posteriorly; as deemed necessary by the history, ligamentous examination, and arthroscopic appearance of the labrum and capsular tissues (Fig 8). As the capsular redundancy and volume are reduced, the labrum is actually widened as it is plicated (Fig 9). Most often, the humeral head sits in a concentrically reduced position at the end of the procedure. This is in contrast to the frequently found antero-inferior subluxation noted at the beginning of the case. The significance of this is unknown, however. At the conclusion of the procedure, the range of motion of the shoulder is assessed when the extremity is removed from the support apparatus. If less than 30 ° of external rotation is present, one should consider revising some of the sutures. This has not, however, been necessary in our experience. We believe that the abducted position of the arm during the procedure protects against excessive inferior plication.
POSTOPERATIVE MANAGEMENT Postoperatively, the arm is held in neutral rotation using an UltraSling (Donjoy Inc, Carlsbad, CA) immobilizer for 3 to 6 weeks. This vanes depending on patient compliance, capsular tissue quality, direction of instability, and surgeon's preference. Some of our early patients were immobiARTHROSCOPIC CAPSULAR PLICATION FOR MDI
Fig 5. A second pinch stitch is passed using the other end of the suture. This creates a horizontal mattress stitch. 241
Fig 6. The two free ends of the suture are tied with a series of half-hitch knots using an arthroscopic knot pusher,
lized in a brace for the first 3 weeks, but we have no longer found this necessary. Gentle hand, wrist, and elbow motion is encouraged in the first 3 weeks. The immobilizer is converted to a sling between 3 and 6 weeks postoperatively and pendulum exercises are started. A formal rehabilitation program is initiated at 6 weeks postoperatively. Progressive exercises are continued until the patient has regained full motion and strength. Contact sports or similar high risk activities are avoided until 6 months postoperatively. A throwing program is begun at 3 months for those wishing to return to throwing sports.
RESULTS More than 50 arthroscopic capsular plications have been performed at SCOI. The initial group of 24 patients with a minimum 2-year follow-up has recently been reviewed. This group consisted of 13 males and 11 females, with an average age of 26.6 years (range, 16 to 45 years). None of these patients had sustained a documented dislocation. Patients with a capsular plication along with repair of a Bankart lesion were not included. All 24 patients were available for questionnaire and examination. Surgical videotapes were also reviewed and all intra-articular findings were noted. Range of external rotation was preserved to within 10 ° of the preoperative value in all but two patients (92%). The average postoperative external rotation was 80.4 °. All shoulders were rated using the Neer criteria, 1 Rowe score, 7 and the American Shoulder and Elbow Surgeons' (ASES) 100-point functional shoulder score. 8
242
Fig 7. Posterior plication is performed while visualizing from the AS portal. The Shuttle Relay is withdrawn from the anterior mid glenoid portal.
The average preoperative ASES score was 63 (range, 32 to 92). The average postoperative score was 86.2 (range, 50 to 100). This improvement was significant (P < .0001). The average postoperative score using the 100-point Rowe score was 79.6 (range, 25 to 100). Using the Neer criteria (satisfactory/unsatisfactory), 19 patients rated satisfactory (79%) and five rated unsatisfactory. Of these five unsatisfactory shoulders, three were involved in workers' compensation cases which had yet to be resolved. A fourth was still actively involved in litigation from a motor vehicle accident at the time of follow-up. S e c o n d - L o o k Arthroscopy
We had an opportunity to observe the arthroscopic appearance of three of the shoulders in our series after capsular plication. Two were having unrelated outpatient procedures and were interested in the arthroscopic appearance of the repair. A 2.7-mm scope was used in these cases. The third patient had persistent impingement-like symptoms and required a subacromial decompression 2 years postoperatively. We were pleased to compare the appearance of the plication at the conclusion of the procedure with that of the second-look arthroscopies. Observing both videotapes, we noted robust capsule formation at the site of the previous plication. In addition, the suture material was well-synovialized with no evidence of adverse synovial reaction. WlCHMAN AND SNYDER
Fig 9. The view of the glenoid showing the effect of capsular plication. The functional width of the glenoid is increased as the capsule is plicated.
Fig 8. Additional sutures are placed anteriorly and posteriorly, creating a pan-capsular plication,
SUMMARY Comparison of results in our initial series with studies reviewing o p e n capsular shift procedures is difficult for several reasons. Few of the c o m m o n l y quoted studies used the same outcome measurements. Some of the studies have been in select athletic populations. Postoperative rehabilitation programs have varied widely. Lastly, all previous studies have reported on all capsular shift procedures, including those with an associated Bankart repair. Our review only included those patients with involuntary shoulder instability w i t h o u t a Bankart lesion. One could argue that this might represent a more challenging group to treat surgically. It appears, however, that this p r o c e d u r e is at least as efficacious as the o p e n surgical alternative. Even in this initial series, r o u g h l y 80% good and excellent results have been found. We do, however, caution the surgeon about the use of this p r o c e d u r e in patients with open workers' compensation claims or litigation cases because of the largely disproportionate n u m b e r of such cases in our unsatisfactory group. We are hopeful that larger intermediate and long-term studies will substantiate our current findings. We anticipate that the results of such studies will surpass those of this preliminary g r o u p due to a learning curve effect. Arthroscopic capsular shift for involuntary anterior,
ARTHROSCOPIC CAPSULAR PLICATION FOR MDI
posterior, and MDI of the shoulder appears to satisfy all of the surgical goals set forth earlier in this article. It also provides for all the w o n d e r f u l advantages of arthroscopic surgery. It is convenient as the patient need not be repositioned on the table. It does require experience in shoulder arthroscopy and necessitates skillful intraarticular knot-tying. We do not r e c o m m e n d this procedure for the casual shoulder arthroscopist and suggest practice on a cadaveric specimen and shoulder m o d e l before attempting this in clinical practice.
REFERENCES 1. Neer CS, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg [Am] 62A:897-908, 1980 2. Cooper R_A,BremsJJ: The inferior capsular-shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg [Am] 74A:15161521, 1992 3. Bigliani LU, Kurzweil PR, Schwartzback CC, et al: Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med 22:578-584,1994 4. Jobe FW, Giangarra CE, Kvitne RS, et al: Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 19:428-434,1991 5. Altchek DW, Warren R: T-plasty modification of the Bankart procedure for multidirectional instability of the anterior inferior type. l Bone Joint Surg [Am] 73A:105-112,1990 6. Duncan R, Savoie FH: Arthroscopic inferior capsular shift for multidirectional instability of the shoulder: A preliminary report. Arthroscopy 9:24-27, 1993 7. Snyder SJ: A complete system for arthroscopy and bursoscopy of the shoulder. Surgical Rounds Orthopaedics July:57-65,1989 8. Rowe CR, Patel D, Southmayd WW: The Bankart procedure, a long term result study. J BoneJoint Surg [AWL]60A:1-16, 1978
243
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. KEY WORDS: multidirectional instability, capsular plication
The initial study of multidirectional instability (MDI) was that of Neer and Foster's classic article in 1980.1 The technique of both the anterior and posterior approaches to the inferior capsular shift procedure were elucidated in this work. In Neer's study, 11 of 40 shoulders had previous surgery. The most common mistaken diagnoses in this group were: unidirectional dislocation, voluntary dislocation, impingement, biceps tendinitis, rotator cuff tear, and glenoid deficiency. In 1992, Cooper and Brems 2 reported their experience with the inferior capsular shift from an anterior approach. Almost half of their patients had previous surgery, mostly consisting of stabilization procedures. Bigliani et al 3 published work on the inferior capsular shift procedure for anterior-inferior instability in athletes. Roughly one quarter of these patients had undergone at least one previous surgical procedure. All of these investigators repaired antero-inferior capsulolabral avulsion (Bankart lesions) with drill holes and sutures when they were identified. The capsular shift was performed after the Bankart repair in these cases. Results of the inferior capsular shift are good. Unfortunately, no two investigators have used the same shoulder scoring criteria in studying MDI. Although only 17 of Neer's 40 shoulders were followed up for 2 years, there were 16 satisfactory and only one unsatisfactory result. In Cooper's studN 91% had no symptomatic instability after 2 years. However, the investigators state that of the athletes in their group, only half were able to return to the same sport. Of those that returned to their sport, some had returned at a lower level of participation. In addition, 21% had weekly or monthly episodes of apprehension. Bigliani had 96% good or excellent results in his series of athletes. Ninety-four percent returned to the same sport, and 75% From the Milwaukee Orthopedic Specialists, Milwaukee, Wl; and the Southern California Orthopedic Institute, Van Nuys, CA. Address reprint requests to MarkT. Wichman, MD, Milwaukee Orthopedic Specialists, 1575 N. RiverCenter Dr, Suite 160, Milwaukee, WI 53212. Copyright © 1997 by W.B. Saunders Company 1060-1872/97/0504-000655.00/0
238
returned to the same competitive level of athletics. Thirtyone percent of the athletic patients in this series had a Bankart lesion identified at surgery that was repaired along with the capsular shift. Complications of inferior capsular shift are not common. Neer noted three cases of axillary nerve neuropraxia, but there were none identified in the other studies. Two other open procedures described for MDI of the shoulder are that of Jobe, and that of Altchek and Warren. Jobe 4 has reported the results of the anterior capsulolabral reconstruction. In this procedure, the subscapularis is split in line with its fibers and the capsule is then shifted on the glenoid side. The inferior leaflet of capsule is sewn on the articular side of the labrum, while the superior leaflet is imbricated over this. This creates a "bumper" effect, according to the Jobe. Of the 25 overhand throwing athletes, 68% returned to at least one season at the previous level of competition. Overall 96% were satisfied with their procedure. Altchek and Warren's 4 series consisted of a retrospective review of patients who had undergone a Bankart procedure and also had an additional procedure for MDI. Most of these patients had actual traumatic dislocations and 90% had Bankart lesions. After repair of the Bankart lesion, the capsule is shifted in a similar fashion to Neer's procedure, except it is performed on the glenoid side. Ninety-five percent good or excellent results are reported with the combined procedure. The arthroscopic literature on treatment of MDI is even more scant. In 1993, Duncan and Savoie 5 published a preliminary report of an arthroscopic technique for inferior capsular shift for MDI. It represented the first study in our search of the literature reporting results from an arthroscopic capsular shift. The procedure includes the division of the anterior and inferior capsule with an end-cutting shaver. The capsule is advanced superiorly including a "key stitch" in the posterior inferior ligament. A transglenoid suture technique is used. Ten consecutive patients were evaluated i to 3 years postoperatively. Nine of 10 had previous dislocations. Four had Bankart lesions found
Operative Techniques in Sports Medicine, Vol 5, No 4 (October), 1997: pp 238-243
during arthroscopy. The Bankart score and Neer system of shoulder grading were used. The average Bankart score was 90, and all 10 patients had a "satisfactory" shoulder according to the satisfactory/unsatisfactory criteria of Neer. There are several surgical principles taken from the above review of the literature on the surgical management of MDI. First, it seems that success may be achieved with capsular shift on either the glenoid or humeral side of the shoulder joint. Each has its own theoretical advantages. Second, the surgical approach must enable the surgeon to readily visualize a Bankart lesion and repair it. This would include recognition of the more uncommon posterior capsulolabral avulsion. Third, the procedure must allow the surgeon to balance the capsular shift anteriorly, inferior, and posteriorly, if necessary. Fourth, one must either leave the subscapularis undisturbed or repair it in an anatomic position if one expects to regain optimal motion. Fifth, the arm must be maintained in a "safe" position during the capsular shift to avoid overtightening of the capsule, which could happen with the arm down at the patient's side. Additionally, it seems beneficial to be able to create a bumper type of effect by thickening or widening the labrum. Optimally, one would use the same suture material used during an open procedure. Lastly, the procedure must have an excellent margin of safety with few complications. This text presents the Southern California Orthopedic Institute's (SCOI) procedure for MDI.
INDICATIONS The technique of arthroscopic capsular plication of the shoulder may be applied to isolated anterior, isolated posterior, or MDI. Our current surgical indications are for those patients with functional impairment of the shoulder secondary to MDI. These patients commonly have a positive sulcus sign combined with anterior or posterior instability. Often these patients have a history of either minor trauma or repetitive overuse. Swimmers and overhand athletes with this problem are often misdiagnosed with subacromial pathology. Patients with documented dislocations or evidence of traumatic dislocation such as a Hill-Sachs lesion, a Bankart lesion found on magnetic resonance imaging, or a fracture of the inferior margin of the glenoid are generally scheduled for a stabilization procedure. At the time of surgery, the amount of capsular redundancy dictates the amount of plication that can be included with their primary repair. The role of rehabilitation as the mainstay of treatment for MDI is not to be underestimated. A prolonged course of rotator cuff strengthening as well as deltoid and scapular stabilization programs are initiated. If the patient is referred after a rehabilitation program elsewhere, we urge them to undergo more therapy under our supervision. This allows for serial examinations over many weeks, improving our knowledge of the patient and the disorder. This may also allow identification of patients with voluntary subluxation or those with secondary gain.
PREOPERATIVE EVALUATION The physical examination of the shoulder is beyond the scope of this article. Some key areas of the preoperative ARTHROSCOPIG CAPSULAR PLICATION FOR MDI
examination are mentioned. We recommend following a standardized worksheet while performing the examination to avoid neglecting aspects of the examination due to forgetfulness, distractions, etc. We prefer to inspect, palpate, check range of motion, perform manual muscle testing and provocative tests of rotator cuff and biceps musculature while the patient is sitting. We also perform gross evaluation of the cervical spine, neurovascular status, degree of inferior laxity (sulcus sign), and check for signs of generalized ligamentous laxity in the sitting position. The next portion of the examination is performed with the patient supine. Range of motion is again assessed with the shoulder abducted 90 ° . Apprehension and apprehension/suppression (ie, relocation test) are noted. We complete the examination with the patient in the lateral position for subluxation testing. Often the normal side will be evaluated first, followed by the symptomatic shoulder. Radiographs are also reviewed. We routinely obtain an anteroposterior view in the plane of the scapula and an axillary lateral. Outlet views and Zanca views of the acromioclavicular (AC) joint are only obtained on an individualized basis in patients with suspected MDI. Often the patients bring in a previous MRI scan, but we do not routinely order MRIs on such patients.
OPERATIVE TECHNIQUE A general anesthetic is administered with or without an interscalene block. An examination under anesthesia is performed and compared to the opposite extremity, especially if there is any uncertainty of the degree or direction of instability. The patient is positioned in the lateral decubitus position on a bean bag. The shoulder is reexamined in the lateral position, then prepared and draped as usual. We prefer to record the preoperative examination under anesthesia on the operative videotape. A separate video camera is uncoupled from the arthroscopy equipment and held a few feet from the patient by the assistant. When this is complete, the shoulder and entire upper extremity is prepared in a sterile fashion. The arm is placed in approximately 70 ° of abduction and roughly 10 lbs of support is applied. We use a three-point shoulder positioning device and foam padded sleeve (STAR Sleeve, Arthrex, Inc, Naples, FL).
DiagnosticArthroscopy A routine videorecorded diagnostic arthroscopy is performed. Visualization begins from the posterior portal. This portal is made 2 to 3 cm inferior and 1 to 2 cm medial to the posterolateral corner of the acromion. The portal is made slightly more superior when posterior plication is anticipated to allow more access to the posterior inferior glenohumeral ligament. The anterior superior (AS) portal is made next. One deviation from our standard technique is the more superior placement of the anterior portal. During instability surgery, this portal is made using an outside-in technique (as opposed to the Wissinger rod technique) with needle localization before making the anterior incision. This allows room inferiorly for the anterior midglenoid (AMG) portal to be made later. These two anterior portals must share the rotator interval. Instrumentation is facilitated by maximizing the skin bridge
239
between them. Once the posterior superior (PS) and AS portals are established, the complete 15-point arthroscopic examination, as described by SJS, 6 is performed. C o m m o n Arthroscopic Findings
In our series, we noted that 16 of 24 patients had fraying of the posterior labrum. Most typical was fraying of the posterior inferior labrum, although two of these patients had flap tears of the posterior labrum. A second classic finding is a patulous posterior capsule and often atrophic superior band of the anterior inferior glenohumeral ligament. Additionally, patients often had anteroinferior subluxation of the shoulder with minimal weight in the arm support apparatus. Other findings, such as superior labruin anterior posterior lesions and partial thickness rotator cuff tears, were not uncommon. A bursoscopy is performed for cases in which articular side rotator cuff pathology is noted during surgery, or if there is preoperative suggestion of bursal-side rotator cuff pathology such as fluid in the bursa on MRI. This is performed when the stabilization is complete. C a p s u l a r Plication
After completing the diagnostic examination and treatment for associated intra-articular pathology, the capsular plication is performed as follows. An anterior midglenoid portal is developed using an outside-in technique. This portal is made approximately 3 cm distal and 2 cm lateral to the AS portal. Again, it is desirable to have as wide a skin bridge between these two portals as possible to facilitate instrumentation. A translucent 8.4-ram screw-in cannula is advanced using a blunt obturator through the anterior soft tissue structures to pierce the anterior capsule just superior to the subscapularis tendon. This cannula allows passage of large suture hooks in the plication procedure. If the surgeon begins with anterior plication, the arthroscope is placed in the PS portal, and a manual synovial rasp or 4.5-mm turbo whisker is used to excoriate the synovium overlying the anterior and inferior capsule and along the edge of the capsular side of the labrum. This should cause the small capillaries to bleed and promote healing of these two opposing surfaces (Fig 1). A 90 ° suture hook (Linvatec Corporation, Largo, FL) loaded with a suture Shuttle Relay is used through the AMG portal and a pinch stitch is created in the anteroinferior capsule (Fig 2). The needle is advanced superior and medially passed through the antero-inferior labrum, creating a 1-cm fold between the capsule and the labrum. The Shuttle Relay is advanced through the suture hook and retrieved through the AS portal with an arthroscopic grasper (Fig 3). A #2 Ethibond suture is loaded in the eyelet of the Shuttle Relay that transports the suture material back through the labruin, capsule, and AMG portal (Fig 4). A second pinch stitch is created i cm from and parallel to the first, and the Shuttle Relay is advanced and retrieved with a grasper. The opposite end of the original suture is loaded into the eyelet of the Shuttle Relay and passed through the tissue. A horizontal mattress suture has now been placed, creating a 1-cm fold between the capsule and the labrum (Fig 5). The two free ends of suture are tied with a loop-handled knot pusher, closing the prepared sides of capsule together with
240
Fig 1. A small rasp is used to excoriate the synovium.
Fig 2. A pinch stitch is created with a 90 ° suture hook. WlCHMAN AND SNYDER
Fig 3. The pinch is advanced superiorly and medially, creating a 1-cm fold between the capsule and labrum. The suture Shuttle Relay is advanced through the needle and retrieved out the AS portal.
Fig 4. The Shuttle Relay loaded with #2 Ethibond is pulled back through the labrum and the capsular pinch, and out the anterior mid glenoid portal.
the knot away from the articular surface (Fig 6). Sutures placed posteriorly are often done with a crescent shaped suture hook from the posterior portal while visualizing from the AS portal (Fig 7). Additional sutures are placed anteriorly; inferiorly, or posteriorly; as deemed necessary by the history, ligamentous examination, and arthroscopic appearance of the labrum and capsular tissues (Fig 8). As the capsular redundancy and volume are reduced, the labrum is actually widened as it is plicated (Fig 9). Most often, the humeral head sits in a concentrically reduced position at the end of the procedure. This is in contrast to the frequently found antero-inferior subluxation noted at the beginning of the case. The significance of this is unknown, however. At the conclusion of the procedure, the range of motion of the shoulder is assessed when the extremity is removed from the support apparatus. If less than 30 ° of external rotation is present, one should consider revising some of the sutures. This has not, however, been necessary in our experience. We believe that the abducted position of the arm during the procedure protects against excessive inferior plication.
POSTOPERATIVE MANAGEMENT Postoperatively, the arm is held in neutral rotation using an UltraSling (Donjoy Inc, Carlsbad, CA) immobilizer for 3 to 6 weeks. This vanes depending on patient compliance, capsular tissue quality, direction of instability, and surgeon's preference. Some of our early patients were immobiARTHROSCOPIC CAPSULAR PLICATION FOR MDI
Fig 5. A second pinch stitch is passed using the other end of the suture. This creates a horizontal mattress stitch. 241
Fig 6. The two free ends of the suture are tied with a series of half-hitch knots using an arthroscopic knot pusher,
lized in a brace for the first 3 weeks, but we have no longer found this necessary. Gentle hand, wrist, and elbow motion is encouraged in the first 3 weeks. The immobilizer is converted to a sling between 3 and 6 weeks postoperatively and pendulum exercises are started. A formal rehabilitation program is initiated at 6 weeks postoperatively. Progressive exercises are continued until the patient has regained full motion and strength. Contact sports or similar high risk activities are avoided until 6 months postoperatively. A throwing program is begun at 3 months for those wishing to return to throwing sports.
RESULTS More than 50 arthroscopic capsular plications have been performed at SCOI. The initial group of 24 patients with a minimum 2-year follow-up has recently been reviewed. This group consisted of 13 males and 11 females, with an average age of 26.6 years (range, 16 to 45 years). None of these patients had sustained a documented dislocation. Patients with a capsular plication along with repair of a Bankart lesion were not included. All 24 patients were available for questionnaire and examination. Surgical videotapes were also reviewed and all intra-articular findings were noted. Range of external rotation was preserved to within 10 ° of the preoperative value in all but two patients (92%). The average postoperative external rotation was 80.4 °. All shoulders were rated using the Neer criteria, 1 Rowe score, 7 and the American Shoulder and Elbow Surgeons' (ASES) 100-point functional shoulder score. 8
242
Fig 7. Posterior plication is performed while visualizing from the AS portal. The Shuttle Relay is withdrawn from the anterior mid glenoid portal.
The average preoperative ASES score was 63 (range, 32 to 92). The average postoperative score was 86.2 (range, 50 to 100). This improvement was significant (P < .0001). The average postoperative score using the 100-point Rowe score was 79.6 (range, 25 to 100). Using the Neer criteria (satisfactory/unsatisfactory), 19 patients rated satisfactory (79%) and five rated unsatisfactory. Of these five unsatisfactory shoulders, three were involved in workers' compensation cases which had yet to be resolved. A fourth was still actively involved in litigation from a motor vehicle accident at the time of follow-up. S e c o n d - L o o k Arthroscopy
We had an opportunity to observe the arthroscopic appearance of three of the shoulders in our series after capsular plication. Two were having unrelated outpatient procedures and were interested in the arthroscopic appearance of the repair. A 2.7-mm scope was used in these cases. The third patient had persistent impingement-like symptoms and required a subacromial decompression 2 years postoperatively. We were pleased to compare the appearance of the plication at the conclusion of the procedure with that of the second-look arthroscopies. Observing both videotapes, we noted robust capsule formation at the site of the previous plication. In addition, the suture material was well-synovialized with no evidence of adverse synovial reaction. WlCHMAN AND SNYDER
Fig 9. The view of the glenoid showing the effect of capsular plication. The functional width of the glenoid is increased as the capsule is plicated.
Fig 8. Additional sutures are placed anteriorly and posteriorly, creating a pan-capsular plication,
SUMMARY Comparison of results in our initial series with studies reviewing o p e n capsular shift procedures is difficult for several reasons. Few of the c o m m o n l y quoted studies used the same outcome measurements. Some of the studies have been in select athletic populations. Postoperative rehabilitation programs have varied widely. Lastly, all previous studies have reported on all capsular shift procedures, including those with an associated Bankart repair. Our review only included those patients with involuntary shoulder instability w i t h o u t a Bankart lesion. One could argue that this might represent a more challenging group to treat surgically. It appears, however, that this p r o c e d u r e is at least as efficacious as the o p e n surgical alternative. Even in this initial series, r o u g h l y 80% good and excellent results have been found. We do, however, caution the surgeon about the use of this p r o c e d u r e in patients with open workers' compensation claims or litigation cases because of the largely disproportionate n u m b e r of such cases in our unsatisfactory group. We are hopeful that larger intermediate and long-term studies will substantiate our current findings. We anticipate that the results of such studies will surpass those of this preliminary g r o u p due to a learning curve effect. Arthroscopic capsular shift for involuntary anterior,
ARTHROSCOPIC CAPSULAR PLICATION FOR MDI
posterior, and MDI of the shoulder appears to satisfy all of the surgical goals set forth earlier in this article. It also provides for all the w o n d e r f u l advantages of arthroscopic surgery. It is convenient as the patient need not be repositioned on the table. It does require experience in shoulder arthroscopy and necessitates skillful intraarticular knot-tying. We do not r e c o m m e n d this procedure for the casual shoulder arthroscopist and suggest practice on a cadaveric specimen and shoulder m o d e l before attempting this in clinical practice.
REFERENCES 1. Neer CS, Foster CR: Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. J Bone Joint Surg [Am] 62A:897-908, 1980 2. Cooper R_A,BremsJJ: The inferior capsular-shift procedure for multidirectional instability of the shoulder. J Bone Joint Surg [Am] 74A:15161521, 1992 3. Bigliani LU, Kurzweil PR, Schwartzback CC, et al: Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med 22:578-584,1994 4. Jobe FW, Giangarra CE, Kvitne RS, et al: Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 19:428-434,1991 5. Altchek DW, Warren R: T-plasty modification of the Bankart procedure for multidirectional instability of the anterior inferior type. l Bone Joint Surg [Am] 73A:105-112,1990 6. Duncan R, Savoie FH: Arthroscopic inferior capsular shift for multidirectional instability of the shoulder: A preliminary report. Arthroscopy 9:24-27, 1993 7. Snyder SJ: A complete system for arthroscopy and bursoscopy of the shoulder. Surgical Rounds Orthopaedics July:57-65,1989 8. Rowe CR, Patel D, Southmayd WW: The Bankart procedure, a long term result study. J BoneJoint Surg [AWL]60A:1-16, 1978
243