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Reverse Rotator Interval Closure
Technical Note
Reverse Rotator Interval Closure William B. Wiley, M.D., William R. Beach, M.D., Sara E. Pearson, Ph.D., and Shannon M. Wolfe, M.D.
Abstract: We describe a technique for reducing capsular volume arthroscopically by shifting the anterior inferior glenohumeral ligament (AIGHL) and capsule up to the top of the subscapularis. This procedure is performed when laxity exists in the absence of a Bankart lesion. The AIGHL is first released from the capsule. This allows sutures to be placed through the capsule inferiorly so that it can be shifted up superiorly during the repair. The AIGHL and capsule are then released from the underlying subscapularis. Sutures are then passed through the capsule and out of the accessory anterior portal, progressing laterally. A BirdBeak suture passer (Arthrex, Naples, FL) is inserted through the superior edge of the subscapularis and is used to grasp each undersurface strand of suture and pull it through and out of the anterior portal. The sutures are then tied sequentially, effectively shifting the capsule and ligament up in a superior direction. Key Words: Arthroscopy—Shoulder— Capsular laxity—Reverse interval closure.
M
ultiple techniques that address capsular laxity in the absence of a true Bankart lesion have been described. These include both arthroscopic and open capsular shift procedures.1-10 The rotator interval is defined as the space between the anterior edge of the supraspinatus and the superior edge of the subscapularis tendons. This space contains the capsule, superior glenohumeral ligament, and coracohumeral ligament.
sulcus sign and anterior and posterior laxity. The patient is then placed in the lateral decubitus position with a beanbag holding him or her in place. An axillary roll is placed under the thorax to relieve pressure on the axillary contents. The shoulder is prepped, draped, and placed in 12 lb of inferolateral traction. A standard posterior portal is established, and
TECHNIQUE The patient is given a general anesthetic, and both shoulders are examined in the supine position for a
From Houston Orthopaedic Surgery and Sports Medicine (W.B.W.), Warner Robins, Georgia; and Orthopaedic Research of Virginia (W.R.B., S.E.P., S.M.W.), Richmond, Virginia, U.S.A. The authors report no conflict of interest. Address correspondence and reprint requests to William R. Beach, M.D., Orthopaedic Research of Virginia, 7660 E Parham Rd, Suite 207, Richmond, VA 23294, U.S.A. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Wiley WB, Beach WR, Pearson SE, Wolfe SM. Reverse rotator interval closure. Arthroscopy 2007;23: 104.e1-104.e4 [doi:10.1016/j.arthro.2006.07.018]. 0749-8063/07/2301-5452$32.00/0 doi:10.1016/j.arthro.2006.07.018
FIGURE 1.
Patulous capsule and pertinent anatomy.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 1 (January), 2007: pp 104.e1-104.e4
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W. B. WILEY ET AL.
FIGURE 2. (A) The capsule is released from the AIGHL by use of a banana blade. This allows a suture punch to be placed through the capsule inferiorly so that it can be shifted up superiorly during the repair. (B) The capsule and AIGHL are released from the subscapularis tendon by use of a shaver.
diagnostic arthroscopy is performed. The anterior portal is established at the superior border of the subscapularis tendon, and the anterior and posterior capsulolabral complex is evaluated. The decision to perform the reverse interval closure is made based on a positive laxity examination with a positive drive-through sign and a blunted or absent labrum in the absence of a Bankart lesion (Fig 1). A banana blade (Beaver model No. 6984; BectonDickinson, Franklin Lakes, NJ) is placed in the anterior portal and is used to release the superior edge of the anterior inferior glenohumeral ligament (AIGHL)
from the capsule (Fig 2A). A shaver is then placed under the ligament and capsule to free them from the underlying subscapularis (Fig 2B). This enhances the ability to shift the capsule and stimulates bleeding to help the capsule scar down in its new position. A NeedlePunch suture passer (Arthrex, Naples, FL), fitted with No. 2 FiberWire (Arthrex) and 2 needlepunch needles, is then used to pass the suture through the capsule (Fig 3A). The NeedlePunch is brought out through the portal, and the needles are cut off; this procedure is repeated 2 to 3 times, progressing laterally (Fig 3B). A BirdBeak suture passer (Ar-
FIGURE 3. (A) The suture is passed through the capsule by use of a NeedlePunch suture passer. (B) The suture is brought through the accessory anterior portal.
REVERSE ROTATOR INTERVAL CLOSURE
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FIGURE 4. (A) The suture is passed through the subscapularis tendon by use of a BirdBeak suture passer, and the undersurface strand of the suture is grasped so that it can be retrieved through the anterior portal. (B) The suture is pulled through and out of the anterior portal.
threx) is then inserted through the superior edge of the subscapularis and used to grasp the undersurface strand of the suture (Fig 4A). The suture is pulled through and out of the anterior portal (Fig 4B). The sutures are then tied sequentially, effectively shifting the capsule and ligament up in a superior direction (Fig 5). If there was a significant sulcus sign preoperatively or if a moderate drive-through sign still exists after the shift, then a standard rotator interval closure is performed by passing the suture through the anterior edge of the supraspinatus and the superior edge of the subscapularis tendons and tying the knot on the bursal side.
DISCUSSION The rotator interval closure brings the supraspinatus down to the subscapularis tendon. The purpose of the reverse rotator interval closure is to bring the AIGHL and capsule up to the top of the subscapularis tendon, effectively decreasing the glenohumeral capsular volume. The first and second authors have been using this technique for approximately 2.5 years with good preliminary results. Of approximately 50 patients who have undergone the reverse rotator interval closure technique, only 2 have shown signs of significant loosening (1 of whom underwent a second stabilization procedure via suture anchors). Another patient has had significant tightness and is working to improve her range of motion. CONCLUSIONS These preliminary observations show that this procedure can adequately stabilize the shoulder when laxity exists in the absence of a Bankart lesion. REFERENCES
FIGURE 5. The retrieved sutures are then tied sequentially, effectively shifting the capsule and AIGHL up in a superior direction. The reverse rotator interval closure is complete.
1. Neer CS II, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am 1980;62:897908. 2. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am 1991;73:105-112.
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3. Bigliani LU, Pollock RG, McIlveen SJ, Endrizzi DP, Flatow EL. Shift of the posteroinferior aspect of the capsule for recurrent posterior glenohumeral instability. J Bone Joint Surg Am 1995;77:1011-1020. 4. Duncan R, Savoie FH III. Arthroscopic inferior capsular shift for multidirectional instability of the shoulder: A preliminary report. Arthroscopy 1993;9:24-27. 5. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic treatment of multidirectional shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 1997;13:418-425. 6. Tauro JC, Carter FM II. Arthroscopic capsular advancement
7. 8. 9. 10.
for anterior and anterior-inferior shoulder instability: A preliminary report. Arthroscopy 1994;10:513-517. Wolf EM, Eakin CL. Arthroscopic capsular plication for posterior shoulder instability. Arthroscopy 1998;14:153-163. Antoniou J, Harryman DT II. Arthroscopic posterior capsular repair. Clin Sports Med 2000;19:101-114. Hewitt M, Getelman MH, Snyder SJ. Arthroscopic management of multidirectional instability: Pancapsular plication. Orthop Clin North Am 2003;34:549-557. Wiley WB, Goradia VK, Pearson SE. Arthroscopic capsular plication-shift. Arthroscopy 2005;21:119-121.
Reverse Rotator Interval Closure William B. Wiley, M.D., William R. Beach, M.D., Sara E. Pearson, Ph.D., and Shannon M. Wolfe, M.D.
Abstract: We describe a technique for reducing capsular volume arthroscopically by shifting the anterior inferior glenohumeral ligament (AIGHL) and capsule up to the top of the subscapularis. This procedure is performed when laxity exists in the absence of a Bankart lesion. The AIGHL is first released from the capsule. This allows sutures to be placed through the capsule inferiorly so that it can be shifted up superiorly during the repair. The AIGHL and capsule are then released from the underlying subscapularis. Sutures are then passed through the capsule and out of the accessory anterior portal, progressing laterally. A BirdBeak suture passer (Arthrex, Naples, FL) is inserted through the superior edge of the subscapularis and is used to grasp each undersurface strand of suture and pull it through and out of the anterior portal. The sutures are then tied sequentially, effectively shifting the capsule and ligament up in a superior direction. Key Words: Arthroscopy—Shoulder— Capsular laxity—Reverse interval closure.
M
ultiple techniques that address capsular laxity in the absence of a true Bankart lesion have been described. These include both arthroscopic and open capsular shift procedures.1-10 The rotator interval is defined as the space between the anterior edge of the supraspinatus and the superior edge of the subscapularis tendons. This space contains the capsule, superior glenohumeral ligament, and coracohumeral ligament.
sulcus sign and anterior and posterior laxity. The patient is then placed in the lateral decubitus position with a beanbag holding him or her in place. An axillary roll is placed under the thorax to relieve pressure on the axillary contents. The shoulder is prepped, draped, and placed in 12 lb of inferolateral traction. A standard posterior portal is established, and
TECHNIQUE The patient is given a general anesthetic, and both shoulders are examined in the supine position for a
From Houston Orthopaedic Surgery and Sports Medicine (W.B.W.), Warner Robins, Georgia; and Orthopaedic Research of Virginia (W.R.B., S.E.P., S.M.W.), Richmond, Virginia, U.S.A. The authors report no conflict of interest. Address correspondence and reprint requests to William R. Beach, M.D., Orthopaedic Research of Virginia, 7660 E Parham Rd, Suite 207, Richmond, VA 23294, U.S.A. E-mail: [email protected] © 2007 by the Arthroscopy Association of North America Cite this article as: Wiley WB, Beach WR, Pearson SE, Wolfe SM. Reverse rotator interval closure. Arthroscopy 2007;23: 104.e1-104.e4 [doi:10.1016/j.arthro.2006.07.018]. 0749-8063/07/2301-5452$32.00/0 doi:10.1016/j.arthro.2006.07.018
FIGURE 1.
Patulous capsule and pertinent anatomy.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 1 (January), 2007: pp 104.e1-104.e4
104.e1
104.e2
W. B. WILEY ET AL.
FIGURE 2. (A) The capsule is released from the AIGHL by use of a banana blade. This allows a suture punch to be placed through the capsule inferiorly so that it can be shifted up superiorly during the repair. (B) The capsule and AIGHL are released from the subscapularis tendon by use of a shaver.
diagnostic arthroscopy is performed. The anterior portal is established at the superior border of the subscapularis tendon, and the anterior and posterior capsulolabral complex is evaluated. The decision to perform the reverse interval closure is made based on a positive laxity examination with a positive drive-through sign and a blunted or absent labrum in the absence of a Bankart lesion (Fig 1). A banana blade (Beaver model No. 6984; BectonDickinson, Franklin Lakes, NJ) is placed in the anterior portal and is used to release the superior edge of the anterior inferior glenohumeral ligament (AIGHL)
from the capsule (Fig 2A). A shaver is then placed under the ligament and capsule to free them from the underlying subscapularis (Fig 2B). This enhances the ability to shift the capsule and stimulates bleeding to help the capsule scar down in its new position. A NeedlePunch suture passer (Arthrex, Naples, FL), fitted with No. 2 FiberWire (Arthrex) and 2 needlepunch needles, is then used to pass the suture through the capsule (Fig 3A). The NeedlePunch is brought out through the portal, and the needles are cut off; this procedure is repeated 2 to 3 times, progressing laterally (Fig 3B). A BirdBeak suture passer (Ar-
FIGURE 3. (A) The suture is passed through the capsule by use of a NeedlePunch suture passer. (B) The suture is brought through the accessory anterior portal.
REVERSE ROTATOR INTERVAL CLOSURE
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FIGURE 4. (A) The suture is passed through the subscapularis tendon by use of a BirdBeak suture passer, and the undersurface strand of the suture is grasped so that it can be retrieved through the anterior portal. (B) The suture is pulled through and out of the anterior portal.
threx) is then inserted through the superior edge of the subscapularis and used to grasp the undersurface strand of the suture (Fig 4A). The suture is pulled through and out of the anterior portal (Fig 4B). The sutures are then tied sequentially, effectively shifting the capsule and ligament up in a superior direction (Fig 5). If there was a significant sulcus sign preoperatively or if a moderate drive-through sign still exists after the shift, then a standard rotator interval closure is performed by passing the suture through the anterior edge of the supraspinatus and the superior edge of the subscapularis tendons and tying the knot on the bursal side.
DISCUSSION The rotator interval closure brings the supraspinatus down to the subscapularis tendon. The purpose of the reverse rotator interval closure is to bring the AIGHL and capsule up to the top of the subscapularis tendon, effectively decreasing the glenohumeral capsular volume. The first and second authors have been using this technique for approximately 2.5 years with good preliminary results. Of approximately 50 patients who have undergone the reverse rotator interval closure technique, only 2 have shown signs of significant loosening (1 of whom underwent a second stabilization procedure via suture anchors). Another patient has had significant tightness and is working to improve her range of motion. CONCLUSIONS These preliminary observations show that this procedure can adequately stabilize the shoulder when laxity exists in the absence of a Bankart lesion. REFERENCES
FIGURE 5. The retrieved sutures are then tied sequentially, effectively shifting the capsule and AIGHL up in a superior direction. The reverse rotator interval closure is complete.
1. Neer CS II, Foster CR. Inferior capsular shift for involuntary inferior and multidirectional instability of the shoulder. A preliminary report. J Bone Joint Surg Am 1980;62:897908. 2. Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am 1991;73:105-112.
104.e4
W. B. WILEY ET AL.
3. Bigliani LU, Pollock RG, McIlveen SJ, Endrizzi DP, Flatow EL. Shift of the posteroinferior aspect of the capsule for recurrent posterior glenohumeral instability. J Bone Joint Surg Am 1995;77:1011-1020. 4. Duncan R, Savoie FH III. Arthroscopic inferior capsular shift for multidirectional instability of the shoulder: A preliminary report. Arthroscopy 1993;9:24-27. 5. McIntyre LF, Caspari RB, Savoie FH III. The arthroscopic treatment of multidirectional shoulder instability: Two-year results of a multiple suture technique. Arthroscopy 1997;13:418-425. 6. Tauro JC, Carter FM II. Arthroscopic capsular advancement
7. 8. 9. 10.
for anterior and anterior-inferior shoulder instability: A preliminary report. Arthroscopy 1994;10:513-517. Wolf EM, Eakin CL. Arthroscopic capsular plication for posterior shoulder instability. Arthroscopy 1998;14:153-163. Antoniou J, Harryman DT II. Arthroscopic posterior capsular repair. Clin Sports Med 2000;19:101-114. Hewitt M, Getelman MH, Snyder SJ. Arthroscopic management of multidirectional instability: Pancapsular plication. Orthop Clin North Am 2003;34:549-557. Wiley WB, Goradia VK, Pearson SE. Arthroscopic capsular plication-shift. Arthroscopy 2005;21:119-121.