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Arthroscopic anterior labral reconstruction using a transglenoid suture technique: Results in the active duty military patient
J. Shoulder Elbow Surg. Volume 4, Number 1, Part 2
THE CONCEPT OF A "SELECTIVE" CAPSULAR SHIFT FOR REPAIR OF ANTERIOR-INFERIOR INSTABILITY OF THE SHOULDER J.J.P. Warner, MD*, D.L. Johnson, MD§,D.N.M. Caborn, MD§, M.D. Miller, MD*, *Center for Sports Med, Univ. of Pitts., Pittsburgh, PA, §Univ of Ky, Lex., KY The purpose of this study was to determine the opinion of the American Shoulder and Elbow Society (ASES) surgeons regarding the importance of arm position during capsular repair for anterior-inferior instability, as well as to report our preliminary results using a modified capsular repair technique which we have termed "selective" capsular shift. Methods, & Results: Part 1 of this study was a survey questionnaire sent to all members of the American Shoulder and Elbow surgeons. Questions asked were: In the case of a patient with posttraumatic, anterior-inferior recurrent shoulder instability, where open repair is being performed, (1) Where do you perform the Capsular Repair (Humerus, mid-capsule, glenoid)?; (2) Is ann position at the time of capsular repair important? (3) What position do you hold the arm in when repairing the capsule (flexion, abduction, external rotation)? 80% of the ASES responded to this survey. 100% agreed that arm position at the time of capsular repair is important, but no more than 50% agreed on any one exact position with respect to flexion, abduction or extemal rotation of the shoulder. Most common response for each position: Flexion 0 ° (50%) (range = 0 - 40°); Abduction 30 ° (34%) (range = 0 - 70 °) & External Rotation 30 ° (37%) (range = 0 - 70°). The most common response cited for importance of arm position was to prevent the loss of external rotation post-operatively. Part II: A modified capsular shift repair termed a "selective" shift performed on 20 patients (average age 23) with post-traumatic recurrent anterior-inferior instability. Patients with atraumatic, multi-directional, or posterior instability were excluded. This procedure, used over the last four years, is based on biomechanical and anatomic studies which suggest that the glenohumeral ligaments of the shoulder function in a loadsharing fashion, with arm position determining which portions of the capsule take up tension. The "selective" shift was performed through a deltopectoral interval. After take-down of the subscapularis, a transverse incision was made in the capsule at the level above the IGHL complex. This was then "T-'ed" on the humeral neck with the creation of superior and inferior capsular flaps. The inferior capsular flap is shifted superiorly and laterally, while holding the shoulder in 10° of forward flexion, 60 ° ABD., & 60 ° of ER. The superior capsular flap is shifted inferiorly and laterally on the humeral neck while maintaining the ann in 0 ° of ABD. & 45 ° of ERo Patients were immobilized for 3 weeks in a sling, & then begun on a progressive, active, assisted ROM program. Average follow-up: 24 months (12 - 38). All patients recorded no pain and full return to pre-morbid level of sports participation. There were no physical signs of recurrent subluxation or instability; 13/20 (75%) had full, equal ROM, 5/20 had ER loss of 10°, & 2/20 had 10 - 20 ° loss of ER. ER was measured with the arm abducted 90 ° & in the coronal plane of the body. Conclusions: While shoulder surgeons agree that ann position at the time of anterior capsular repair is important, there is no consensus as to the best position. Our technique selectively tightens the inferior and superior capsule by shifting with the arm placed so that the ligaments are in a functional position. This appears to achieve both mobility and stability in a preliminary follow-up of patients.
Abstracts $3
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ARTHROSCOPIC RECONSTRUCTION OF RECURRENT TRAUMATIC ANTERIOR INSTABILITY F. H. S a v o i e , III, M . D . In a prospective study all 163 patients with traumatic anterior instability of the shoulder that presented between January 1989 and December 1991, were managed by arthroscopic suture reconstruction. All patients had documented e v i d e n c e of t w o or m o r e dislocations of t h e shoulder ( a v e r a g e = ii). T h e a v e r a g e p r e o p e r a t i v e B a n k a r t s c o r e w a s 15. O n e h u n d r e d s i x t y one out of 163 patients were reevaluated fifteen to 51 months postoperatively. Overall, 147 (91%) of t h e p a t i e n t s r a t e d as s a t i s f a c t o r y w h i l e 14 (9%) r a t e d as u n s a t i s f a c t o r y . The average postoperative Bankart score for all patients was 89. The results provided statistically significant differences by age grouping. 16 of 21 patient (76%) 16 o r u n d e r achieved a satisfactory result. Patients in t h e c o l l e g e a g e r a n g e of 18 to 23 s h o w e d a 90% satisfactory rate. 97.5% of patients 22 and older achieved a satisfactory result.
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ARTHB~SCOPIC ANTERIOR LABRAL RECONSTRUCTION U S I N G A T R A N S G L E N O I D S U T U R E TECHNIQUE: RESULTS IN T H E A C T I V E D U T Y M I L I T A R Y PATIENT. T.S.
Mologne, M.D., J.M. Lapoint, M.D., W.D. Morin, M.D., J. Zilberfarb, M.D., T.J. O'Brien, M.D. Purpose: Report the clinical outcome of arthroscopic labral reconstruction using a transglenoid suture technique in a young military population ( ave F/U 30 months ). S,,"m~ry of m e t h o d s a n d results: 64 pts (65 shoulders ) with traumatic anterior labral tears underwent arthroscopic reconstruction using a transglenoid suture technique. 48 pts with 49 procedures were available for F/U. 17 of the 41 pts with preoperative dislocation or subluxation had recurrent instability. Using the Rowe rating system, excellent or good results were seen in 53%; fair or poor results were seen in 47%. The overall perioperative complication rate was 14%. Suprascapular nerve palsy occurred in 6% ( 3 ) . Non-compliance with the 6 weeks postoperative immobilization protocol was seen in 20 pts (41%). I~nobilization for six weeks postoperatively correlated with a lower recurrence rate in the patients with a history of glenohumeral dislocation (p=0.007). C o n c l u s i o n s : Arthroscopic labral reconstruction using transglenoid sutures resulted in an unacceptably high failure rate in the young, physically active military patient. Post-op i~obilization for 6 wks correlated with a lower recurrence rate. This technique jeopardizes the suprascapular nerve.
THE CONCEPT OF A "SELECTIVE" CAPSULAR SHIFT FOR REPAIR OF ANTERIOR-INFERIOR INSTABILITY OF THE SHOULDER J.J.P. Warner, MD*, D.L. Johnson, MD§,D.N.M. Caborn, MD§, M.D. Miller, MD*, *Center for Sports Med, Univ. of Pitts., Pittsburgh, PA, §Univ of Ky, Lex., KY The purpose of this study was to determine the opinion of the American Shoulder and Elbow Society (ASES) surgeons regarding the importance of arm position during capsular repair for anterior-inferior instability, as well as to report our preliminary results using a modified capsular repair technique which we have termed "selective" capsular shift. Methods, & Results: Part 1 of this study was a survey questionnaire sent to all members of the American Shoulder and Elbow surgeons. Questions asked were: In the case of a patient with posttraumatic, anterior-inferior recurrent shoulder instability, where open repair is being performed, (1) Where do you perform the Capsular Repair (Humerus, mid-capsule, glenoid)?; (2) Is ann position at the time of capsular repair important? (3) What position do you hold the arm in when repairing the capsule (flexion, abduction, external rotation)? 80% of the ASES responded to this survey. 100% agreed that arm position at the time of capsular repair is important, but no more than 50% agreed on any one exact position with respect to flexion, abduction or extemal rotation of the shoulder. Most common response for each position: Flexion 0 ° (50%) (range = 0 - 40°); Abduction 30 ° (34%) (range = 0 - 70 °) & External Rotation 30 ° (37%) (range = 0 - 70°). The most common response cited for importance of arm position was to prevent the loss of external rotation post-operatively. Part II: A modified capsular shift repair termed a "selective" shift performed on 20 patients (average age 23) with post-traumatic recurrent anterior-inferior instability. Patients with atraumatic, multi-directional, or posterior instability were excluded. This procedure, used over the last four years, is based on biomechanical and anatomic studies which suggest that the glenohumeral ligaments of the shoulder function in a loadsharing fashion, with arm position determining which portions of the capsule take up tension. The "selective" shift was performed through a deltopectoral interval. After take-down of the subscapularis, a transverse incision was made in the capsule at the level above the IGHL complex. This was then "T-'ed" on the humeral neck with the creation of superior and inferior capsular flaps. The inferior capsular flap is shifted superiorly and laterally, while holding the shoulder in 10° of forward flexion, 60 ° ABD., & 60 ° of ER. The superior capsular flap is shifted inferiorly and laterally on the humeral neck while maintaining the ann in 0 ° of ABD. & 45 ° of ERo Patients were immobilized for 3 weeks in a sling, & then begun on a progressive, active, assisted ROM program. Average follow-up: 24 months (12 - 38). All patients recorded no pain and full return to pre-morbid level of sports participation. There were no physical signs of recurrent subluxation or instability; 13/20 (75%) had full, equal ROM, 5/20 had ER loss of 10°, & 2/20 had 10 - 20 ° loss of ER. ER was measured with the arm abducted 90 ° & in the coronal plane of the body. Conclusions: While shoulder surgeons agree that ann position at the time of anterior capsular repair is important, there is no consensus as to the best position. Our technique selectively tightens the inferior and superior capsule by shifting with the arm placed so that the ligaments are in a functional position. This appears to achieve both mobility and stability in a preliminary follow-up of patients.
Abstracts $3
4
ARTHROSCOPIC RECONSTRUCTION OF RECURRENT TRAUMATIC ANTERIOR INSTABILITY F. H. S a v o i e , III, M . D . In a prospective study all 163 patients with traumatic anterior instability of the shoulder that presented between January 1989 and December 1991, were managed by arthroscopic suture reconstruction. All patients had documented e v i d e n c e of t w o or m o r e dislocations of t h e shoulder ( a v e r a g e = ii). T h e a v e r a g e p r e o p e r a t i v e B a n k a r t s c o r e w a s 15. O n e h u n d r e d s i x t y one out of 163 patients were reevaluated fifteen to 51 months postoperatively. Overall, 147 (91%) of t h e p a t i e n t s r a t e d as s a t i s f a c t o r y w h i l e 14 (9%) r a t e d as u n s a t i s f a c t o r y . The average postoperative Bankart score for all patients was 89. The results provided statistically significant differences by age grouping. 16 of 21 patient (76%) 16 o r u n d e r achieved a satisfactory result. Patients in t h e c o l l e g e a g e r a n g e of 18 to 23 s h o w e d a 90% satisfactory rate. 97.5% of patients 22 and older achieved a satisfactory result.
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ARTHB~SCOPIC ANTERIOR LABRAL RECONSTRUCTION U S I N G A T R A N S G L E N O I D S U T U R E TECHNIQUE: RESULTS IN T H E A C T I V E D U T Y M I L I T A R Y PATIENT. T.S.
Mologne, M.D., J.M. Lapoint, M.D., W.D. Morin, M.D., J. Zilberfarb, M.D., T.J. O'Brien, M.D. Purpose: Report the clinical outcome of arthroscopic labral reconstruction using a transglenoid suture technique in a young military population ( ave F/U 30 months ). S,,"m~ry of m e t h o d s a n d results: 64 pts (65 shoulders ) with traumatic anterior labral tears underwent arthroscopic reconstruction using a transglenoid suture technique. 48 pts with 49 procedures were available for F/U. 17 of the 41 pts with preoperative dislocation or subluxation had recurrent instability. Using the Rowe rating system, excellent or good results were seen in 53%; fair or poor results were seen in 47%. The overall perioperative complication rate was 14%. Suprascapular nerve palsy occurred in 6% ( 3 ) . Non-compliance with the 6 weeks postoperative immobilization protocol was seen in 20 pts (41%). I~nobilization for six weeks postoperatively correlated with a lower recurrence rate in the patients with a history of glenohumeral dislocation (p=0.007). C o n c l u s i o n s : Arthroscopic labral reconstruction using transglenoid sutures resulted in an unacceptably high failure rate in the young, physically active military patient. Post-op i~obilization for 6 wks correlated with a lower recurrence rate. This technique jeopardizes the suprascapular nerve.