- Email: [email protected]
Multidirectional Shoulder Instability: Arthroscopic Labral Augmentation
Technical Note
Multidirectional Shoulder Instability: Arthroscopic Labral Augmentation Enrico Gervasi, M.D., Enrico Sebastiani, M.D., and Alessandro Spicuzza, M.D.
Abstract: Capsulolabral augmentation is one of the most used arthroscopic techniques to address multidirectional instability of the shoulder. Given the thin and weak capsule seen in the affected patients, reconstruction in this subset of patients can be particularly challenging. This arthroscopic technique aims to reduce the capsular volume and deepen the glenoid socket through the creation of a particularly voluminous “bumper” along the glenoid bone. Increasing the depth of the glenoid facilitates a concavity-compression stabilizing effect and, therefore, shoulder stability, especially midrange stability. This technique aims to augment the bump of the standard capsulolabral reconstruction by using a resorbable surgical mesh derived from porcine skin.
M
ultidirectional shoulder instability represents an ongoing challenge for orthopaedic surgeons. Surgical treatment should be considered for patients showing debilitating or invalidating symptomatology despite proper rehabilitation. Among the most common surgical procedures, capsuloligamentous techniquesdwhich include open inferior capsular shift, arthroscopic plication, and thermal capsulorrhaphydare the most frequently used1; thermal capsulorrhaphy has been progressively abandoned. By realizing a standard-height bumper, arthroscopic capsuloplasty can increase the stability ratio by 25%, therefore improving shoulder stability.2 Yet, this approach can prove inadequate in case of poor-quality capsuloligamentous structures caused by constitutional hyperlaxity or due to one or more surgical procedures. The surgical technique we recommend consists of a glenoid labrum reconstruction performed with a resorbable surgical mesh derived from porcine skin able to increase glenoid height and surface. This technique is an additional step in traditional capsuloplasty
From the Department of Orthopaedics and Traumatology, Ospedale Civile di Latisana (E.G., A.S.), Latisana (UD); and Università degli Studi di Perugia (E.S.), Perugia, Italy. The authors report the following potential conflicts of interest or sources of funding: E.G. receives support from Lima Stemless Shoulder Prosthesis. Received March 22, 2016; accepted September 12, 2016. Address correspondence to Enrico Sebastiani, M.D., Via Leti 100, 63900 Fermo, Italy. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16243/$36.00 http://dx.doi.org/10.1016/j.eats.2016.09.025
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procedures and it is not an alternative to them. We think that increasing the glenoid depth could reduce the frequency and extent of tensile solicitation of the humeral head on the ligamentous structures. This methodology is particularly recommended in cases in which traditional procedures are burdened with a substantial rate of recurrences: Atraumatic instability, even voluntary, in symptomatic patients Multidirectional recurrent atraumatic instability in patients with constitutional laxity Surgical revision, even following a Latarjet procedure, in patients with constitutional laxity, fragile capsule, and no bone deficiency When capsule weakness is an unexpected intraoperative evaluation finding A dislocation caused by a low-energy trauma showing no bone deficiency points toward labrum augmentation using grafts.
Surgical Technique Physical features of the glenoid bone have been reported as 39 3 mm in the superior-inferior dimension, 29 3 mm in the anteroposterior dimension of the lower half, and 23 3 mm in the anteroposterior dimension of the upper half. The space available for graft placement is 45 5 mm long. This value corresponds to the lower half of the circumference inscribed in the subequatorial portion of the glenoid, and it is calculated as follows: (diameter pi)/2, so that (29 þ 3 pi)/2. The glenoid labrum increases joint depth by up to 50%.3 Anatomical studies showed that
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Fig 1. Patient in lateral decubitus, left shoulder. The 3 portals held by a cannula are visible: posterior, anterosuperior, and midglenoid. The anterosuperior portal is mainly used for intra-articular viewing during the procedure.
glenoid cavity depth measures 9 mm in the superiorinferior direction, and 5 mm in the anteroposterior dimension. A greater depth of the glenoid cavity provides better stability to the shoulder. Therefore, the graft should be more than 45 mm long (perimeter of the inferior glenoid bone) and 2.5 mm thick (regular glenoid labrum). Arthroscopic Technique Video 1 is a case description of our technique in a left shoulder. The patient is placed in a lateral decubitus position and 3 to 4 kg traction is applied with the upper limb at 50 of abduction and 20 of anterior flexion. We open 3 to 4 arthroscopic portals: 3 standard (posterior, anterosuperior, midglenoid), held by a cannula (Fig 1); the accessory (posterolateral) (Fig 2) one can be useful
Fig 2. Patient in lateral decubitus, left shoulder, posterior viewing of the left shoulder. A posterolateral portal (dermographic pen) can be used for a better anchor placement in the inferior portion of the glenoid bone (6 o’clock). A red arrow marks the standard posterior portal.
Fig 3. Patient in lateral decubitus, left shoulder, camera in the anterosuperior portal. Capsuloligamentous structures already detached from the subequatorial portion of the glenoid bone. The tool lifts the disconnected medial margin of the capsule and shows the decorticated glenoid neck.
to insert the most distal anchor at the 6 o’clock position. For the midglenoid portal, we recommend the use of a cannula with the removable cannula cap (Clera-Trac, Smith & Nephew, Hull, UK), which facilitates graft insertion. For the other portals, we use standard cannulas (Threaded Clear Cannula with Obturator 8.5 mm 75 mm, DePuy Mitek, Raynham, MA).
Fig 4. Patient in lateral decubitus, left shoulder, camera in the anterosuperior portal. Capsulolabroplasty is performed using double-loaded all-suture anchors. Anchor threads at the 6 o’clock position already passed through the capsular tissue; using a shuttle technique, we are working in the posteroinferior quadrant, with the second anchor seated at the 4.30 position. In this phase, a South-North shift of the capsular tissue needs to be obtained; therefore, the tool must emerge distally from the anchor.
ARTHROSCOPIC LABRAL AUGMENTATION
Fig 5. Patient in lateral decubitus, left shoulder, camera in the anterosuperior portal. The capsulolabroplasty is finished, the capsuloligamentous structures are retensioned, and a new glenoid labrum (called “bumper”) is reconstructed.
The glenoid labrum (thin, when present) and the capsule are detached from the 3 to 9 o’clock position (Fig 3), the scapular neck is decorticated, and then the capsulolabral reconstruction is performed according to the surgeon’s preferred method (Figs 4 and 5). Graft Preparation The graft length needed can vary; 5 cm is sufficient for all cases in which the prevalent direction of the
Fig 6. The membrane is folded to assume a cylindrical shape. Two surgical clamps fix the membrane at the extremities. To keep the shape during suturing and ease the needle passage, straight 18-gauge needles pass through the folded graft. All needles have to be inserted in the same direction.
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Fig 7. The Vicryl No.1 (Ethicon, Somerville, NJ), tied to form a loop, is inserted in an eyed needle. Passing through the straight needles, the eyed needle pierces the graft and the suture thread along with it. The same procedure is to be performed with further needles, managing the suture with a SpeedWhip technique.
instability is the inferior one. The maximum available graft length is 10 cm. We use a 5- to 10-mm-thick graftdat least twice the size of the regular glenoid labrumdthat is added to the new labrum obtained by capsular plication. The excess membrane is cut out. The membrane (DX Reinforcement Matrix, Arthrex, Naples, FL) is folded, and then sutured by the “SpeedWhip” technique. We use a resorbable suture Vicryl No. 1 (Ethicon, Somerville, NJ) that makes the membrane
Fig 8. A resorbable thread keeps the cylindrical shape of the graft. Three LabralTapes (Arhtrex, Naples, FL) pass through the graft at both ends and in the center. The free limbs of each LabralTape come out of the same side of the graft to shape a “U.” The central LabralTape has a different color to ease suture management within the articulation. We recommend tying together the loose ends of each LabralTape. The 2 LabralTapes at the extremities are used to anchor the graft to the anterior and to the posterior margins of the glenoid. The central LabralTape is used to anchor the graft at the 6 o’clock position. The posterior LabralTape is used to pull the graft inside the joint.
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Fig 9. One of the LabralTapes at the extremity of the graft is inserted into the articulation through the midglenoid portal and retrieved from the posterior one. Applying traction to this LabralTape, the graft is pulled into the joint through the midglenoid portal.
stiff and keep its shape until it is inserted into the joint. The 2 free limbs of the suture are tied to form a loop that is armed on an eyed needle. Straight 18-gauge needles (Fig 6) ease the needle suture passage through the folded membrane, which is particularly rigid: they pass through the membrane, carrying on their tips that transport the suture; by retreating, these straight needles allow a smooth needle and thread passage through the membrane (Fig 7). Both limbs of 3 more sutures, LabralTapes (Arthrex), are passed through the graft: in its middle, anterior, and posterior part. Each LabralTape passes through the graft to shape a “U” with its free limbs coming out of the same side of the graft itself. These 3 LabralTapes are then used to secure the graft to the glenoid bone. The temporary tying of the limbs of each suture and the use
Fig 10. Patient in lateral decubitus, left shoulder, camera in the anteroposterior portal. Once a hole has been made at the 6 o’clock position, the central LabralTape (the one differently colored) is anchored to the glenoid with a knotless anchor through the midglenoid portal.
of different color sutures can ease suture management (Fig 8). In this case we color the central FiberTabe blue. Graft Insertion and Fixation After the removal of the cannula cap from the midglenoid portal, the LabralTape of one end of the graft is inserted into the joint through the midglenoid portal, and pulled out from the posterior portal (Fig 9) until the graft enters into the joint. At this point, the 2 limbs of the posterior LabralTape come out from the posterior portal, whereas the limbs of the other 2 LabralTapes (the middle and the anterior ones) are still located in the midglenoid portal; the graft is in place into the joint. The graft fixation point to the glenoid starts as inferior as possible: the central LabralTape of the graft (Fig 10) is
Fig 11. Patient in lateral decubitus, left shoulder, camera in the anteroposterior portal. The graft is anchored to the posterior margin of the glenoid with a knotless anchor (red arrow) through the posterior portal.
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ARTHROSCOPIC LABRAL AUGMENTATION Table 2. Advantages and Disadvantages of Arthroscopic Labral Augmentation
Advantages: 1. Standard arthroscopic shoulder setup and portals 2. Familiar arthroscopic passing and shuttling techniques 3. Biological membrane always available in the operating room 4. Bumper effect increase and theoretical facilitation of the concavity-compression mechanism Disadvantages: 1. Surgery duration is extended. This technique is an additional step in the traditional capsuloplasty procedure 2. Costs increase
Fig 12. Patient in lateral decubitus, left shoulder, camera in the anteroposterior portal. The graft made of resorbable surgical mesh derived from porcine skin is anchored to the glenoid rim along the entire subequatorial region.
secured at the 6 o’clock position by a knotless sutureanchor (PEEK PushLock 2.9 mm 15.5 mm, Arthrex); it comes through the posterolateral portal or the midglenoid one. Two further knotless suture anchors complete the fixation: one anteriorly and one posteriorly (Fig 11). Variable amount of additional single-suture implants stabilize the graft that is finally placed around the whole perimeter of the subequatorial portion of the glenoid (Fig 12). The fixation could be extended proximally to the anterior, posterior, or both sides, depending on the prevalent instability direction. Postoperative Care A shoulder sling should keep the affected shoulder immobilized for 6 weeks, followed by nightly use of the sling for the subsequent month. Scapulothoracic proprioceptive recovery starts before the surgical procedure, and immediately resumes during the first postoperative period. Table 1. Pearls and Pitfalls of Arthroscopic Labral Augmentation Pearls: 1. Use a LabralTape that has a different color at the center of the graft 2. Tie together the free limbs of each LabralTape to ease suture management 3. For the midglenoid portal, use a cannula through which the graft can pass 4. Once inside the articulation, push the graft into the axillary pouch to increase the maneuvering area in inserting the anchor at the 6 o’clock position Pitfall: 1. If the graft rotates around its own axis when pulled into the articulation, suture management can be difficult
Once the support is removed, glenohumeral joint range of motion recovery can start: initially only through active exercise to avoid stressing the capsule. To avoid muscle atrophy, a mild isometric strengthening exercise can be started when the sling is removed. After 2 to 3 months, a rotator cuff and scapular stabilizer isotonic reinforcing program can begin to improve dynamic stability and neuromuscular control. Sport-related training should not begin before 6 to 9 months after surgery, and full articular recovery (especially in abduction and extra rotation) should not be made before 1 year after the procedure.
Discussion The labrum not only provides an attachment area for the glenohumeral ligaments, but it also increases the joint surface area and deepens the glenoid cavity; it generates negative intra-articular pressure and produces a “wedge-like blocking effect.” Active coaptation of the humeral head against the glenoid bone seems to be a more relevant element of stability than negative intra-articular pressure or ligament tension.4 An increase of the concave joint depthdand therefore of the “stability ratio”dhelps active compression forces in maintaining joint stability. Active stabilization is important when ligaments, which stretch only at maximum grades of articolarity, are not tensioned. If active stabilization is insufficient, it determines midrange instability. Lippitt et al.5 proved that the resection of the glenoid labrum in 10 anatomical specimens resulted in a stability decrease in all directions, calculating that the labrum contributes to shoulder stability by approximately 20%; the highest value (37%) was detected in the posteroinferior direction compared with others (18%). A following study6 downsized the average contribution of the labrum to shoulder stability to 10%. In the inferior region of the glenoid bone, contrary to the superior one, the labrum still plays a relevant role, and its resection produces an increase of humeral head translation. Older studies probably overestimate glenoid labrum contribution, because their authors, while producing the experimental lesion, also damaged the capsule and the glenohumeral ligament insertion.
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Pouliart and Gagey,7 who conducted a study on the sequential arthroscopic resection of the glenoid labrum without damaging the capsuloligamentous structures, determined an inferior labrum contribution to shoulder stability compared with the results of previous studies; the resection of the anterior labrum increases humeral translation in 50% of the specimens, whereas the resection of the inferior labrum increases inferior translation in just 20% of samples. Cadaveric experiments are often conducted using specimens derived by elderly individuals, whose glenoid labrum suffered age-related deterioration. A reduction of the glenoid-labrum contact surface due to agingdas long as the glenoid surface remains unchangeddis caused by the deteriorating of the glenoid labrum, that becomes thinner.8 These studies likely underestimated the effective role played by the glenoid labrum. In any case, although capsuloligamentous structures have a major role in ensuring shoulder stability in healthy subjects if compared with the glenoid labrum, when these structures are of poor quality and their biomechanical functioning is not optimal, glenoid labrum contribution to shoulder stability becomes crucial. In patients with these features, it is important to combine capsuloligamentous reconstruction with labrum augmentation, as a means to provide additional stabilization, taking advantage from the “wedge-like blocking effect” and increasing the glenoid cavity depth. Capsuloplasty surgical techniques, open or arthroscopic, are used to treat multidirectional instabilities, but they might not be conclusive when the capsular tissue is weak or excessively elastic. Recurrence rate in these patients is similar (7.5% to 10%) both after arthroscopic capsulolabral reconstruction and open capsular shift,9,10 because these procedures operate through the same biomechanical principle by retensioning capsuloligamentous structures. Moreover, elastic tissues are at risk to fray due to continuous solicitations by the humeral head, thus explaining results deterioration in time.11 With such thin tissues, the new labrum, obtained through capsular plication, is too soft and cannot apply an efficient mechanical effect. In a cadaver study, Yamamoto12 proved how a new labrum just reconstructed (thus made up of fresh and compressible tissue) does not increase shoulder instability. This technique adds the stabilizing effect of a stiff and high bumper to the biomechanical benefits of standard capsuloplasty techniques. Published techniques foreseeing the use of a graft for anatomical structure augmentation aim to reconstruct the anterior shoulder capsule,13-16 the glenohumeral ligaments,17,18 and eventually the anterior glenoid labrum only. No technique currently takes into consideration the importance of performing
a complete subequatorial, anterior, inferior, and posterior augmentation of the glenoid labrum to reduce tension on the capsuloligamentous repair and improve active centering of the humeral head (concavity compression). We believe, in fact, that the augmentation of a barrier (new labrum) at the periphery of the glenoid rim can reduce the frequency and intensity of humeral head solicitation on the ligaments, protecting them from further plastic deformation. The graft acts as a barrier by reducing the energy of the humerus translation. This technique can increase the “wedge-like blocking effect” of the newly reconstructed bump, thus reducing the humeral head slipping toward to the bottom during abduction by hastening its rotation. We suggest labrum augmentation also for patients with laxity showing postsurgical recurrences with no bone defect. Glenoid labrum augmentation is added to capsulolabral plasty, and it thus increases either operating time or costs (devices and membrane). This is a reproducible and standardizable technique involving portals and setups commonly used during shoulder arthroscopy, without requiring specific surgical tools. Finally, the used membrane can be stored in package and be available, when needed, in the operating room (Tables 1 and 2). Arthroscopic capsuloplasty with labrum augmentation can be a very useful and reproducible technique in patients with constitutional laxity or weak capsuloligamentous tissue; it should be considered in cases of multidirectional instability without relevant bone defect.
References 1. Gaskill TR, Taylor DC, Millet PJ. Management of multidirectional instability of the shoulder. J Am Acad Orthop Surg 2011;19:758-767. 2. Metcalf MH, Pon DJ, Harryman DT II. Capsulolabral augmentation increase glenohumeral stability in the cadaver shoulder. J Shoulder Elbow Surg 2001;10:532-538. 3. Apostolakos J, Yang JS, Hoberman AR, et al. Glenoid labrum. In: Bain GI, Itoi E, Di Giacomo G, Sugaya H, eds. Normal and pathological anatomy of the shoulder. Berlin: Springer-Verlag, 2015;83-91. 4. Warner JJ, Bowen MK, Deng X, Torzilli PA, Warren RF. Effect of joint compression on inferior stability of the glenohumeral joint. J Shoulder Elbow Surg 1999;11:141149. 5. Lippitt SB, Vanderhooft JE, Harris SL, Sidles JA, Harryman DT, Matsen FA. Glenohumeral stability from concavity-compression: A quantitative analysis. J Shoulder Elbow Surg 1993;2:27-35. 6. Halder AM, Kuhl BS, Zobitz ME, Larson D, An KN. Effects of the glenoid labrum and glenohumeral abduction on stability of the shoulder joint through concavitycompression. J Bone Joint Surg Am 2001;83:1062-1069.
ARTHROSCOPIC LABRAL AUGMENTATION 7. Pouliart N, Gagey O. The effect of isolated labrum resection on shoulder stability. Knee Surg Sports Traumatol Arthrosc 2006;14:301-308. 8. Itoi E, Morrey BF, An KN. Biomechanics of the shoulder. In: Rockwood CA, Matsen FA, Wirth MA, Lippit SB, eds. The shoulder. 4th ed. Philadelphia: Elsevier, 2009;213-265. 9. Longo UG, Rizzello G, Loppini M, et al. Multidirectional instability of the shoulder: A systematic review. Arthroscopy 2015;31:2431-2443. 10. Chen D, Goldberg J, Herald J, Critchley I, Barmare A. Effect of surgical management on multidirectional instability of the shoulder: A meta-analysis. Knee Surg Sports Traumatol Arthrosc 2016;24:630-639. 11. Merolla G, Cerciello S, Chillemi C, Paladini P, De Santis E, Porcellini G. Multidirectional instability of the shoulder: Biomechanics, clinical presentation, and treatment strategies. Eur J Orthop Surg Traumatol 2015;25:975-985. 12. Yamamoto N, Muraki T, Sperling JW, et al. Does the “bumper” created during Bankart repair contribute to shoulder stability? J Shoulder Elbow Surg 2013;22:828-834. 13. Iannotti JP, Antoniou J, Williams GR, Ramsey ML. Iliotibial band reconstruction for treatment of glenohumeral
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instability associated with irreparable capsular deficiency. J Shoulder Elbow Surg 2002;11:618-623. Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM. Instability of the shoulder after arthroplasty. J Bone Joint Surg Am 1993;75:492-497. Alcid JG, Powell SE, Tibone JE. Revision anterior capsular shoulder stabilization using hamstring tendon autograft and tibialis tendon allograft reinforcement: Minimum two-year follow-up. J Shoulder Elbow Surg 2007;16:268272. Warner JJ, Venegas AA, Lehtinen JT, Macy JJ. Management of capsular deficiency of the shoulder. A report of three cases. J Bone Joint Surg Am 2002;84: 1668-1671. Braun S, Millet PJ. Open anterior capsular reconstruction of the shoulder for chronic instability using tibialis anterior allograft. Tech Shoulder Elbow Surg 2008;9: 102-107. Lazarus MD, Harryman DT II. Open repair for anterior instability. In: Warner JJP, Iannotti JP, Gerber C, eds. Complex and revision problems in shoulder surgery. Philadelphia: Lippincott-Raven, 1997;47-64.
Multidirectional Shoulder Instability: Arthroscopic Labral Augmentation Enrico Gervasi, M.D., Enrico Sebastiani, M.D., and Alessandro Spicuzza, M.D.
Abstract: Capsulolabral augmentation is one of the most used arthroscopic techniques to address multidirectional instability of the shoulder. Given the thin and weak capsule seen in the affected patients, reconstruction in this subset of patients can be particularly challenging. This arthroscopic technique aims to reduce the capsular volume and deepen the glenoid socket through the creation of a particularly voluminous “bumper” along the glenoid bone. Increasing the depth of the glenoid facilitates a concavity-compression stabilizing effect and, therefore, shoulder stability, especially midrange stability. This technique aims to augment the bump of the standard capsulolabral reconstruction by using a resorbable surgical mesh derived from porcine skin.
M
ultidirectional shoulder instability represents an ongoing challenge for orthopaedic surgeons. Surgical treatment should be considered for patients showing debilitating or invalidating symptomatology despite proper rehabilitation. Among the most common surgical procedures, capsuloligamentous techniquesdwhich include open inferior capsular shift, arthroscopic plication, and thermal capsulorrhaphydare the most frequently used1; thermal capsulorrhaphy has been progressively abandoned. By realizing a standard-height bumper, arthroscopic capsuloplasty can increase the stability ratio by 25%, therefore improving shoulder stability.2 Yet, this approach can prove inadequate in case of poor-quality capsuloligamentous structures caused by constitutional hyperlaxity or due to one or more surgical procedures. The surgical technique we recommend consists of a glenoid labrum reconstruction performed with a resorbable surgical mesh derived from porcine skin able to increase glenoid height and surface. This technique is an additional step in traditional capsuloplasty
From the Department of Orthopaedics and Traumatology, Ospedale Civile di Latisana (E.G., A.S.), Latisana (UD); and Università degli Studi di Perugia (E.S.), Perugia, Italy. The authors report the following potential conflicts of interest or sources of funding: E.G. receives support from Lima Stemless Shoulder Prosthesis. Received March 22, 2016; accepted September 12, 2016. Address correspondence to Enrico Sebastiani, M.D., Via Leti 100, 63900 Fermo, Italy. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16243/$36.00 http://dx.doi.org/10.1016/j.eats.2016.09.025
Arthroscopy Techniques, Vol
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procedures and it is not an alternative to them. We think that increasing the glenoid depth could reduce the frequency and extent of tensile solicitation of the humeral head on the ligamentous structures. This methodology is particularly recommended in cases in which traditional procedures are burdened with a substantial rate of recurrences: Atraumatic instability, even voluntary, in symptomatic patients Multidirectional recurrent atraumatic instability in patients with constitutional laxity Surgical revision, even following a Latarjet procedure, in patients with constitutional laxity, fragile capsule, and no bone deficiency When capsule weakness is an unexpected intraoperative evaluation finding A dislocation caused by a low-energy trauma showing no bone deficiency points toward labrum augmentation using grafts.
Surgical Technique Physical features of the glenoid bone have been reported as 39 3 mm in the superior-inferior dimension, 29 3 mm in the anteroposterior dimension of the lower half, and 23 3 mm in the anteroposterior dimension of the upper half. The space available for graft placement is 45 5 mm long. This value corresponds to the lower half of the circumference inscribed in the subequatorial portion of the glenoid, and it is calculated as follows: (diameter pi)/2, so that (29 þ 3 pi)/2. The glenoid labrum increases joint depth by up to 50%.3 Anatomical studies showed that
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Fig 1. Patient in lateral decubitus, left shoulder. The 3 portals held by a cannula are visible: posterior, anterosuperior, and midglenoid. The anterosuperior portal is mainly used for intra-articular viewing during the procedure.
glenoid cavity depth measures 9 mm in the superiorinferior direction, and 5 mm in the anteroposterior dimension. A greater depth of the glenoid cavity provides better stability to the shoulder. Therefore, the graft should be more than 45 mm long (perimeter of the inferior glenoid bone) and 2.5 mm thick (regular glenoid labrum). Arthroscopic Technique Video 1 is a case description of our technique in a left shoulder. The patient is placed in a lateral decubitus position and 3 to 4 kg traction is applied with the upper limb at 50 of abduction and 20 of anterior flexion. We open 3 to 4 arthroscopic portals: 3 standard (posterior, anterosuperior, midglenoid), held by a cannula (Fig 1); the accessory (posterolateral) (Fig 2) one can be useful
Fig 2. Patient in lateral decubitus, left shoulder, posterior viewing of the left shoulder. A posterolateral portal (dermographic pen) can be used for a better anchor placement in the inferior portion of the glenoid bone (6 o’clock). A red arrow marks the standard posterior portal.
Fig 3. Patient in lateral decubitus, left shoulder, camera in the anterosuperior portal. Capsuloligamentous structures already detached from the subequatorial portion of the glenoid bone. The tool lifts the disconnected medial margin of the capsule and shows the decorticated glenoid neck.
to insert the most distal anchor at the 6 o’clock position. For the midglenoid portal, we recommend the use of a cannula with the removable cannula cap (Clera-Trac, Smith & Nephew, Hull, UK), which facilitates graft insertion. For the other portals, we use standard cannulas (Threaded Clear Cannula with Obturator 8.5 mm 75 mm, DePuy Mitek, Raynham, MA).
Fig 4. Patient in lateral decubitus, left shoulder, camera in the anterosuperior portal. Capsulolabroplasty is performed using double-loaded all-suture anchors. Anchor threads at the 6 o’clock position already passed through the capsular tissue; using a shuttle technique, we are working in the posteroinferior quadrant, with the second anchor seated at the 4.30 position. In this phase, a South-North shift of the capsular tissue needs to be obtained; therefore, the tool must emerge distally from the anchor.
ARTHROSCOPIC LABRAL AUGMENTATION
Fig 5. Patient in lateral decubitus, left shoulder, camera in the anterosuperior portal. The capsulolabroplasty is finished, the capsuloligamentous structures are retensioned, and a new glenoid labrum (called “bumper”) is reconstructed.
The glenoid labrum (thin, when present) and the capsule are detached from the 3 to 9 o’clock position (Fig 3), the scapular neck is decorticated, and then the capsulolabral reconstruction is performed according to the surgeon’s preferred method (Figs 4 and 5). Graft Preparation The graft length needed can vary; 5 cm is sufficient for all cases in which the prevalent direction of the
Fig 6. The membrane is folded to assume a cylindrical shape. Two surgical clamps fix the membrane at the extremities. To keep the shape during suturing and ease the needle passage, straight 18-gauge needles pass through the folded graft. All needles have to be inserted in the same direction.
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Fig 7. The Vicryl No.1 (Ethicon, Somerville, NJ), tied to form a loop, is inserted in an eyed needle. Passing through the straight needles, the eyed needle pierces the graft and the suture thread along with it. The same procedure is to be performed with further needles, managing the suture with a SpeedWhip technique.
instability is the inferior one. The maximum available graft length is 10 cm. We use a 5- to 10-mm-thick graftdat least twice the size of the regular glenoid labrumdthat is added to the new labrum obtained by capsular plication. The excess membrane is cut out. The membrane (DX Reinforcement Matrix, Arthrex, Naples, FL) is folded, and then sutured by the “SpeedWhip” technique. We use a resorbable suture Vicryl No. 1 (Ethicon, Somerville, NJ) that makes the membrane
Fig 8. A resorbable thread keeps the cylindrical shape of the graft. Three LabralTapes (Arhtrex, Naples, FL) pass through the graft at both ends and in the center. The free limbs of each LabralTape come out of the same side of the graft to shape a “U.” The central LabralTape has a different color to ease suture management within the articulation. We recommend tying together the loose ends of each LabralTape. The 2 LabralTapes at the extremities are used to anchor the graft to the anterior and to the posterior margins of the glenoid. The central LabralTape is used to anchor the graft at the 6 o’clock position. The posterior LabralTape is used to pull the graft inside the joint.
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Fig 9. One of the LabralTapes at the extremity of the graft is inserted into the articulation through the midglenoid portal and retrieved from the posterior one. Applying traction to this LabralTape, the graft is pulled into the joint through the midglenoid portal.
stiff and keep its shape until it is inserted into the joint. The 2 free limbs of the suture are tied to form a loop that is armed on an eyed needle. Straight 18-gauge needles (Fig 6) ease the needle suture passage through the folded membrane, which is particularly rigid: they pass through the membrane, carrying on their tips that transport the suture; by retreating, these straight needles allow a smooth needle and thread passage through the membrane (Fig 7). Both limbs of 3 more sutures, LabralTapes (Arthrex), are passed through the graft: in its middle, anterior, and posterior part. Each LabralTape passes through the graft to shape a “U” with its free limbs coming out of the same side of the graft itself. These 3 LabralTapes are then used to secure the graft to the glenoid bone. The temporary tying of the limbs of each suture and the use
Fig 10. Patient in lateral decubitus, left shoulder, camera in the anteroposterior portal. Once a hole has been made at the 6 o’clock position, the central LabralTape (the one differently colored) is anchored to the glenoid with a knotless anchor through the midglenoid portal.
of different color sutures can ease suture management (Fig 8). In this case we color the central FiberTabe blue. Graft Insertion and Fixation After the removal of the cannula cap from the midglenoid portal, the LabralTape of one end of the graft is inserted into the joint through the midglenoid portal, and pulled out from the posterior portal (Fig 9) until the graft enters into the joint. At this point, the 2 limbs of the posterior LabralTape come out from the posterior portal, whereas the limbs of the other 2 LabralTapes (the middle and the anterior ones) are still located in the midglenoid portal; the graft is in place into the joint. The graft fixation point to the glenoid starts as inferior as possible: the central LabralTape of the graft (Fig 10) is
Fig 11. Patient in lateral decubitus, left shoulder, camera in the anteroposterior portal. The graft is anchored to the posterior margin of the glenoid with a knotless anchor (red arrow) through the posterior portal.
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ARTHROSCOPIC LABRAL AUGMENTATION Table 2. Advantages and Disadvantages of Arthroscopic Labral Augmentation
Advantages: 1. Standard arthroscopic shoulder setup and portals 2. Familiar arthroscopic passing and shuttling techniques 3. Biological membrane always available in the operating room 4. Bumper effect increase and theoretical facilitation of the concavity-compression mechanism Disadvantages: 1. Surgery duration is extended. This technique is an additional step in the traditional capsuloplasty procedure 2. Costs increase
Fig 12. Patient in lateral decubitus, left shoulder, camera in the anteroposterior portal. The graft made of resorbable surgical mesh derived from porcine skin is anchored to the glenoid rim along the entire subequatorial region.
secured at the 6 o’clock position by a knotless sutureanchor (PEEK PushLock 2.9 mm 15.5 mm, Arthrex); it comes through the posterolateral portal or the midglenoid one. Two further knotless suture anchors complete the fixation: one anteriorly and one posteriorly (Fig 11). Variable amount of additional single-suture implants stabilize the graft that is finally placed around the whole perimeter of the subequatorial portion of the glenoid (Fig 12). The fixation could be extended proximally to the anterior, posterior, or both sides, depending on the prevalent instability direction. Postoperative Care A shoulder sling should keep the affected shoulder immobilized for 6 weeks, followed by nightly use of the sling for the subsequent month. Scapulothoracic proprioceptive recovery starts before the surgical procedure, and immediately resumes during the first postoperative period. Table 1. Pearls and Pitfalls of Arthroscopic Labral Augmentation Pearls: 1. Use a LabralTape that has a different color at the center of the graft 2. Tie together the free limbs of each LabralTape to ease suture management 3. For the midglenoid portal, use a cannula through which the graft can pass 4. Once inside the articulation, push the graft into the axillary pouch to increase the maneuvering area in inserting the anchor at the 6 o’clock position Pitfall: 1. If the graft rotates around its own axis when pulled into the articulation, suture management can be difficult
Once the support is removed, glenohumeral joint range of motion recovery can start: initially only through active exercise to avoid stressing the capsule. To avoid muscle atrophy, a mild isometric strengthening exercise can be started when the sling is removed. After 2 to 3 months, a rotator cuff and scapular stabilizer isotonic reinforcing program can begin to improve dynamic stability and neuromuscular control. Sport-related training should not begin before 6 to 9 months after surgery, and full articular recovery (especially in abduction and extra rotation) should not be made before 1 year after the procedure.
Discussion The labrum not only provides an attachment area for the glenohumeral ligaments, but it also increases the joint surface area and deepens the glenoid cavity; it generates negative intra-articular pressure and produces a “wedge-like blocking effect.” Active coaptation of the humeral head against the glenoid bone seems to be a more relevant element of stability than negative intra-articular pressure or ligament tension.4 An increase of the concave joint depthdand therefore of the “stability ratio”dhelps active compression forces in maintaining joint stability. Active stabilization is important when ligaments, which stretch only at maximum grades of articolarity, are not tensioned. If active stabilization is insufficient, it determines midrange instability. Lippitt et al.5 proved that the resection of the glenoid labrum in 10 anatomical specimens resulted in a stability decrease in all directions, calculating that the labrum contributes to shoulder stability by approximately 20%; the highest value (37%) was detected in the posteroinferior direction compared with others (18%). A following study6 downsized the average contribution of the labrum to shoulder stability to 10%. In the inferior region of the glenoid bone, contrary to the superior one, the labrum still plays a relevant role, and its resection produces an increase of humeral head translation. Older studies probably overestimate glenoid labrum contribution, because their authors, while producing the experimental lesion, also damaged the capsule and the glenohumeral ligament insertion.
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E. GERVASI ET AL.
Pouliart and Gagey,7 who conducted a study on the sequential arthroscopic resection of the glenoid labrum without damaging the capsuloligamentous structures, determined an inferior labrum contribution to shoulder stability compared with the results of previous studies; the resection of the anterior labrum increases humeral translation in 50% of the specimens, whereas the resection of the inferior labrum increases inferior translation in just 20% of samples. Cadaveric experiments are often conducted using specimens derived by elderly individuals, whose glenoid labrum suffered age-related deterioration. A reduction of the glenoid-labrum contact surface due to agingdas long as the glenoid surface remains unchangeddis caused by the deteriorating of the glenoid labrum, that becomes thinner.8 These studies likely underestimated the effective role played by the glenoid labrum. In any case, although capsuloligamentous structures have a major role in ensuring shoulder stability in healthy subjects if compared with the glenoid labrum, when these structures are of poor quality and their biomechanical functioning is not optimal, glenoid labrum contribution to shoulder stability becomes crucial. In patients with these features, it is important to combine capsuloligamentous reconstruction with labrum augmentation, as a means to provide additional stabilization, taking advantage from the “wedge-like blocking effect” and increasing the glenoid cavity depth. Capsuloplasty surgical techniques, open or arthroscopic, are used to treat multidirectional instabilities, but they might not be conclusive when the capsular tissue is weak or excessively elastic. Recurrence rate in these patients is similar (7.5% to 10%) both after arthroscopic capsulolabral reconstruction and open capsular shift,9,10 because these procedures operate through the same biomechanical principle by retensioning capsuloligamentous structures. Moreover, elastic tissues are at risk to fray due to continuous solicitations by the humeral head, thus explaining results deterioration in time.11 With such thin tissues, the new labrum, obtained through capsular plication, is too soft and cannot apply an efficient mechanical effect. In a cadaver study, Yamamoto12 proved how a new labrum just reconstructed (thus made up of fresh and compressible tissue) does not increase shoulder instability. This technique adds the stabilizing effect of a stiff and high bumper to the biomechanical benefits of standard capsuloplasty techniques. Published techniques foreseeing the use of a graft for anatomical structure augmentation aim to reconstruct the anterior shoulder capsule,13-16 the glenohumeral ligaments,17,18 and eventually the anterior glenoid labrum only. No technique currently takes into consideration the importance of performing
a complete subequatorial, anterior, inferior, and posterior augmentation of the glenoid labrum to reduce tension on the capsuloligamentous repair and improve active centering of the humeral head (concavity compression). We believe, in fact, that the augmentation of a barrier (new labrum) at the periphery of the glenoid rim can reduce the frequency and intensity of humeral head solicitation on the ligaments, protecting them from further plastic deformation. The graft acts as a barrier by reducing the energy of the humerus translation. This technique can increase the “wedge-like blocking effect” of the newly reconstructed bump, thus reducing the humeral head slipping toward to the bottom during abduction by hastening its rotation. We suggest labrum augmentation also for patients with laxity showing postsurgical recurrences with no bone defect. Glenoid labrum augmentation is added to capsulolabral plasty, and it thus increases either operating time or costs (devices and membrane). This is a reproducible and standardizable technique involving portals and setups commonly used during shoulder arthroscopy, without requiring specific surgical tools. Finally, the used membrane can be stored in package and be available, when needed, in the operating room (Tables 1 and 2). Arthroscopic capsuloplasty with labrum augmentation can be a very useful and reproducible technique in patients with constitutional laxity or weak capsuloligamentous tissue; it should be considered in cases of multidirectional instability without relevant bone defect.
References 1. Gaskill TR, Taylor DC, Millet PJ. Management of multidirectional instability of the shoulder. J Am Acad Orthop Surg 2011;19:758-767. 2. Metcalf MH, Pon DJ, Harryman DT II. Capsulolabral augmentation increase glenohumeral stability in the cadaver shoulder. J Shoulder Elbow Surg 2001;10:532-538. 3. Apostolakos J, Yang JS, Hoberman AR, et al. Glenoid labrum. In: Bain GI, Itoi E, Di Giacomo G, Sugaya H, eds. Normal and pathological anatomy of the shoulder. Berlin: Springer-Verlag, 2015;83-91. 4. Warner JJ, Bowen MK, Deng X, Torzilli PA, Warren RF. Effect of joint compression on inferior stability of the glenohumeral joint. J Shoulder Elbow Surg 1999;11:141149. 5. Lippitt SB, Vanderhooft JE, Harris SL, Sidles JA, Harryman DT, Matsen FA. Glenohumeral stability from concavity-compression: A quantitative analysis. J Shoulder Elbow Surg 1993;2:27-35. 6. Halder AM, Kuhl BS, Zobitz ME, Larson D, An KN. Effects of the glenoid labrum and glenohumeral abduction on stability of the shoulder joint through concavitycompression. J Bone Joint Surg Am 2001;83:1062-1069.
ARTHROSCOPIC LABRAL AUGMENTATION 7. Pouliart N, Gagey O. The effect of isolated labrum resection on shoulder stability. Knee Surg Sports Traumatol Arthrosc 2006;14:301-308. 8. Itoi E, Morrey BF, An KN. Biomechanics of the shoulder. In: Rockwood CA, Matsen FA, Wirth MA, Lippit SB, eds. The shoulder. 4th ed. Philadelphia: Elsevier, 2009;213-265. 9. Longo UG, Rizzello G, Loppini M, et al. Multidirectional instability of the shoulder: A systematic review. Arthroscopy 2015;31:2431-2443. 10. Chen D, Goldberg J, Herald J, Critchley I, Barmare A. Effect of surgical management on multidirectional instability of the shoulder: A meta-analysis. Knee Surg Sports Traumatol Arthrosc 2016;24:630-639. 11. Merolla G, Cerciello S, Chillemi C, Paladini P, De Santis E, Porcellini G. Multidirectional instability of the shoulder: Biomechanics, clinical presentation, and treatment strategies. Eur J Orthop Surg Traumatol 2015;25:975-985. 12. Yamamoto N, Muraki T, Sperling JW, et al. Does the “bumper” created during Bankart repair contribute to shoulder stability? J Shoulder Elbow Surg 2013;22:828-834. 13. Iannotti JP, Antoniou J, Williams GR, Ramsey ML. Iliotibial band reconstruction for treatment of glenohumeral
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