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Treatment of Glenohumeral Subluxation Using Electrothermal Capsulorrhaphy
Treatment of Glenohumeral Subluxation Using Electrothermal Capsulorrhaphy Kirk L. Wong, M.D., Charles L. Getz, M.D., George L. Yeh, M.D., Matthew Ramsey, M.D., Joseph P. Iannotti, M.D., Ph.D., and Gerald R. Williams, Jr., M.D.
Purpose: The purpose of this study was to review the results of a relatively homogenous group of patients with glenohumeral subluxation without labral pathology who were treated with an electrothermal capsulorrhaphy procedure. Type of Study: Case series without controls. Methods: From 1997 to 1998, 42 patients underwent electrothermal capsulorrhaphy using a monopolar radiofrequency probe (Oratec Interventions, Menlo Park, CA). Patients with prior capsular repairs, labral pathology that required repair, or capsular avulsion injuries were excluded from the study. Thirty-one patients met the inclusion criteria. Patients had a minimum of 2 years of follow-up (mean, 25 months), and a mean age of 25 years (range, 16 to 38 years). All of the patients had previously failed conservative treatment. There were 25 patients with unidirectional anterior instability, 2 patients with unidirectional inferior instability, 1 patient with unidirectional posterior instability, and 3 patients with multidirectional instability. The patients were assessed using a modified American Shoulder and Elbow Surgeons (ASES) score that examined pain (30 points), function (60 points), and patient satisfaction (10 points). In addition, subjective stability was assessed using a 10-point scale. Results: The average modified ASES score increased to 88 points from 56 preoperatively (P ⬍ .01). The average subjective stability scale increased to 8.5 from 4.4 preoperatively (P ⬍ .01). Nineteen patients (61%) had an excellent result, 4 (13%) had a good result, 5 (16%) had a fair result, and 3 (10%) had a poor result; 22 of 26 patients who participated in sports were able to return to their preinjury level of play. The subset of patients with isolated anterior instability had results similar to the overall group. There were no instances of axillary neuritis or other neurologic injury. Conclusions: In carefully selected patients with shoulder instability, including unidirectional anterior instability without associated labral pathology, electrothermal capsulorrhaphy was effective and had few complications. Level of Evidence: Level IV, case series without controls. Key Words: Thermal capsulorrhaphy— Shoulder—Instability.
T
he thermal effects of laser or radiofrequency energy on collagen are well known.1-12 The clinical applications of thermal energy in the man-
From the Departments of Orthopaedic Surgery, the Hospitals of the University of Pennsylvania (K.L.W., C.L.G., G.L.Y., M.R., G.R.W.), Philadelphia, Pennsylvania; and the Cleveland Clinic Foundation (J.P.I.), Cleveland, Ohio, U.S.A. Address correspondence and reprint requests to Gerald R. Williams, Jr., M.D., Penn Musculoskeletal Institute, One Cupp Pavilion, 39th and Market Sts, Philadelphia, PA 19104, U.S.A. E-mail: [email protected] © 2005 by the Arthroscopy Association of North America 0749-8063/05/2108-4250$30.00/0 doi:10.1016/j.arthro.2005.05.003
agement of glenohumeral instability, however, are still evolving. Both laser and radiofrequency energy have been used in isolation or as an adjunct to other stabilization procedures to treat glenohumeral instability.13-17 The reported results of these procedures are difficult to interpret because of potential differences in patient selection criteria, method of energy application, and type of instability. The purpose of this study was to review the clinical results of electrothermal capsulorrhaphy using one method of energy delivery (monopolar radiofrequency) in a selected group of patients with glenohumeral subluxation without labral tears or prior labral repair. The hypothesis is that, in this group of instability
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patients, thermal capsulorrhaphy is an effective treatment. METHODS Between April 1997 and November 1998, 42 patients underwent thermal capsulorrhaphy using a monopolar radiofrequency probe (Oratec Interventions, Menlo Park, CA). All patients had failed conservative treatment that included a minimum of 3 months of therapeutic exercises. Patients with multidirectional instability or generalized laxity had a minimum of 12 months of conservative therapy. Patients with prior stability procedures, including capsular procedures, labral pathology that required arthroscopic or open repair, or humeral capsular avulsion injuries, were excluded from the analysis. Five shoulders had each undergone 1 previous shoulder procedure. These included 2 diagnostic arthroscopies with minor labral debridements, 1 diagnostic arthroscopy with minor rotator cuff debridement, 1 arthroscopic acromioplasty, and 1 arthroscopic distal clavicle resection. None of the patients had any prior capsulolabral repairs or reconstructions and none had labral detachment requiring repair. Patients with previous labral debridement were included because this was not considered a stabilization procedure. Thirty-five patients satisfied our inclusion criteria with a minimum of 2 years of follow-up. Four patients were lost to follow-up and were excluded from the study. The remaining 31 patients form the basis of our study. Preoperative and postoperative evaluation included history, physical examination, and completion of a patient self-assessment questionnaire. Results were graded using a modified American Shoulder and Elbow Surgeons (ASES) shoulder score (100 points) based on pain (30 points), function (60 points), and patient satisfaction (10 points). An excellent result was identified if the modified ASES score was 90 to 100 points, a good result required a modified ASES score of 80 to 89, a fair result required a modified ASES score of 70 to 79, and a poor result occurred if the modified ASES score was less than 70 points. In addition, patients rated their stability using a 10-point scale. Patients were also questioned about their level of athletic performance, endurance, and stability. The average age of our patients was 25 years (range, 16 to 38 years). There were 23 male and 8 female patients. Mean follow-up was 25 months (range, 24 to 30 months). The dominant extremity was involved in 17 patients. The time from the initial complaint of shoulder dysfunction to surgical inter-
vention averaged 27 months (range, 4 to 96 months). Twenty-nine patients (91%) had recurrent glenohumeral subluxation with no history of dislocation. Subluxation is defined as a feeling of instability by the patient without a documented frank glenohumeral dislocation. Two patients had sustained a single dislocation. Twelve patients were recreational athletes, 5 were high-school athletes, and 9 were college athletes. Thirteen (50%) of these patients were involved in sports requiring overhead use of the limb such as baseball pitching, tennis, volleyball, and swimming. Twentytwo patients recalled a specific injury; 14 sports injuries, 3 motor vehicle accidents, 1 fall from a height of 6 feet, 1 blow to the anterior aspect of his shoulder, and 3 heavy lifting injuries. Three patients had Workers’ Compensation claims. Nine patients recalled no specific injury to their shoulder and attributed their symptoms to repetitive overhead athletic activity such as throwing, tennis serving, swimming, or volleyball spiking. An examination under anesthesia was performed to quantify range of motion, and humeral head translation. Quantification of range of motion included maximal elevation in the scapular plane, external rotation with the arm at the side, external rotation with the arm at 90° of elevation in the scapular plane, and internal rotation with the arm at 90° of elevation in the scapular plane. Anterior translation was tested in neutral, 45°, and 90° of abduction, similar to that described by Altchek et al.18 For posterior instability, the amount of posterior translation was determined in neutral, 45°, and 90° of abduction. Inferior translation was examined with the arm at the side and was observed as the arm was externally rotated. Inferior translation that remained despite external rotation indicated rotator interval pathology The effect of humeral rotation was also observed during translational testing. Inferior translation was tested in varying amounts of external rotation from 0° to maximal external rotation. Anterior translation was tested in varying degrees of external rotation from neutral to maximal rotation in all 3 positions of abduction. Posterior translation was tested in varying degrees of internal rotation from neutral to maximal internal rotation in all 3 positions of abduction. Range of motion and translation were compared with the opposite, normal side. The decision to perform thermal capsulorrhaphy was based on the presence of a side-to-side difference in translation and rotation.19 Increased external rotation with the arm abducted to 90° indicated pathology
ELECTROTHERMAL CAPSULORRHAPHY of the anterior inferior glenohumeral ligament. Increased internal rotation in the abducted position indicated pathology of the posterior inferior glenohumeral ligament. A side-to-side difference of external rotation with the arm at the side indicates rotator interval pathology. Surgery was then aimed toward shortening the elongated structures as directed by the examination under anesthesia. Surgical Technique All cases were performed with patients in the beach-chair position. A complete diagnostic arthroscopy was performed to rule out any labral avulsions. The portals used for placement of the arthroscopic radiofrequency probe varied with the region(s) of the glenohumeral capsule requiring shrinking. For shrinkage of the rotator interval, anterior capsule, and the anterior portion of the inferior glenohumeral ligament, an anterior portal that penetrated the joint through the rotator interval immediately superior to the subscapularis tendon was used. During shrinkage of the posterior capsule and the posterior portion of the inferior glenohumeral ligament, a posterior portal was used. The region(s) of the capsule undergoing shrinkage was determined based on the preoperative history and concordant physical examination as well as the results of the examination under anesthesia. The rotator interval was treated if history of inferior instability was confirmed by the following findings during examination under anesthesia: increased external rotation with the arm at the side, increased inferior translation with the arm at the side, and an increase in the amount of external rotation required to reduce the sulcus sign compared with the other arm. The anterior capsule and the anterior portion of the inferior glenohumeral ligament were treated if the patient exhibited a history of anterior instability combined with the following findings under anesthesia: increased external rotation with the arm at 90° abduction in the plane of the scapula, increased anterior translation with the arm at 45° and 90° of scapular plane elevation, and increased external rotation required to decrease translation compared with the normal side. The posterior capsule was treated if the patient exhibited signs and symptoms of posterior instability and an examination under anesthesia with the following: increased internal rotation with the arm at 90° of scapular plane abduction, increased posterior translation with the arm in neutral rotation and 45° and 90° of scapular plane abduction, and an increased amount of internal rotation required
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to decrease the posterior translation compared with the normal side. The radiofrequency energy was applied using an arthroscopic probe attached to a first-generation Oratec monopolar radiofrequency generator preset at 40 W of power and 65°C. As mentioned earlier, the axillary recess was treated only when there was evidence of increased external rotation or internal rotation with the arm at 90° of elevation. The region of the capsule requiring shrinking was treated with the radiofrequency probe by passing the tip of the probe over the capsule in an inferior to superior direction starting immediately distal to the labrum. The next pass was made parallel to the first one, with 5 mm of normal capsule between the 2 stripes. This was continued laterally until the humeral attachment was encountered. This resulted in 3 or 4 stripes in all areas of the capsule treated. Postoperative Rehabilitation Aftercare was individualized according to the region(s) of the capsule undergoing shrinkage. Patients with isolated anterior instability were placed in a sling for 3 weeks. Pendulum exercises were begun at 3 weeks, use of the arm for activities of daily living was allowed at this time as well. Six weeks postoperatively, passive mobilization of the joint was instituted, with a limitation of no external rotation stretching with the arm at 90° of elevation in the scapular plane. Active use of the arm was allowed with the same restrictions as indicated for passive therapy at 6 weeks. External rotation stretching in the abducted position was instituted 10 to 12 weeks postoperatively if external rotation in this position was lacking 15° or more than the opposite shoulder. Rotator cuff, deltoid, and scapular strengthening exercises were also instituted at 6 weeks postoperatively. Return to overhead sport was not allowed until 6 months postoperatively. Resumption of preinjury sport level was deferred until 6 to 9 months postoperatively. Patients with isolated inferior instability were prescribed a sling for 6 weeks. Pendulum exercises were instituted at 4 to 6 weeks postoperatively. Passive mobilization was instituted 6 weeks postoperatively, with a limitation of no external rotation stretching. Active motion for activities of daily living were allowed at 6 weeks. External rotation stretching with the arm at the side was instituted 10 to 12 weeks postoperatively if external rotation loss with the arm at the side, compared with the normal side, was greater than 15°. Rotator cuff, deltoid, and scapular strengthening
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exercises were instituted 6 weeks postoperatively. Return to full activity was allowed 6 to 9 months postoperatively. After treatment for multidirectional or posterior instability, postoperative immobilization consisted of a brace with the arm in approximately 20° of abduction and 30° of external rotation for 6 weeks. After brace removal, the patients were asked to use their arm within their limits of pain for activities of daily living that did not involve lifting and to begin pendulum exercises. Passive stretching was instituted 10 to 12 weeks postoperatively if motion loss in any direction, compared with the normal side, was greater than 15°. Rotator cuff, deltoid, and scapular strengthening exercises were instituted 6 weeks postoperatively. Return to sport or full activity was withheld until 6 to 9 months postoperatively. Statistical Analysis Preoperative and postoperative modified ASES scores were compared using a paired t test. In those patients who required another operation, the modified ASES score before the second procedure was used. The preoperative and postoperative instability scores were compared using the nonparametric Wilcoxon rank-sum test. All statistical analysis was performed using Intercooled Stata 5.0 (Stata, College Station, TX). RESULTS Thirty-one patients underwent selective thermal capsulorrhaphy following asymmetric examination under anesthesia. There were 25 patients with unidirectional anterior instability, 2 patients with inferior instability, 1 patient with posterior instability, and 3 patients with multidirectional instability (1 inferior/ posterior, and 2 anterior/posterior). The 25 patients with unidirectional anterior instability underwent shrinkage of the anterior capsule and the anterior portion of the inferior glenohumeral ligament. The 2 patients with isolated inferior instability underwent shrinkage of the rotator interval capsule. The patient with unidirectional posterior instability underwent shrinkage of the posterior capsule and posterior portion of the inferior glenohumeral ligament. The patient with inferior and posterior instability underwent shrinkage of the rotator interval capsule, the posterior capsule, and the posterior portion of the inferior glenohumeral ligament. The 2 patients with anterior and posterior instability underwent shrinkage of the ante-
TABLE 1. Results of Patients Who Underwent Electrothermal Capsulorrhaphy
Modified ASES score Stability rating
Preoperative Scores
Postoperative Scores
P Values
56 (12–86) 4.4 (0–10)
88 (46–88) 8.5 (0–10)
P ⬍ .0001 P ⬍ .0001
rior capsule, the anterior portion of the inferior glenohumeral ligament, the posterior capsule, and the posterior portion of the inferior glenohumeral ligament. Four patients had generalized ligamentous laxity with hyperextension of the metacarpophalangeal joints, hyperabduction of the thumb, and recurvatum of the elbows. One patient had unidirectional inferior instability and 3 others had multidirectional instability patterns. The average modified ASES score increased to 88 points (range, 46-100) from 56 preoperatively (range, 12-86; P ⬍ .0001). The average subjective stability scale increased to 8.5 (range, 0-10) from 4.4 preoperatively (range, 0-10; P ⬍ .0001) (Table 1). Nineteen patients (61%) had an excellent result, 4 (13%) had a good result, 5 (16%) had a fair result, and 3 (10%) had a poor result of all those treated. When analyzing the 25 patients with isolated anterior instability as a separate subset of patients, 16 patients (64%) had excellent results, 3 patients (12%) had good results, 5 patients (20%) had fair results, and 1 patient (4%) had a poor result. Both patients with bidirectional anteroposterior instability had excellent results. One of the 2 patients with isolated inferior instability had an excellent result; the other patient had a poor result, with a subjective stability score of 5 of 10 compared with 2 of 10 preoperatively. The patient with bidirectional inferior/ posterior instability had a good result. The only patient with isolated posterior instability had a poor result. Twenty-two (85%) of 26 patients who participated in recreational or competitive athletics reported return to their preinjury level of function in their respective sports. One patient with anterior subluxation and an early good result sustained a traumatic anterior dislocation while playing basketball 2 months postoperatively, against our advice. Before his thermal capsulorrhaphy, he had sustained an anterior subluxation without dislocation as a result of a motor vehicle accident. Despite aggressive rehabilitation after a brief period of immobilization, he suffered recurrent shoulder dislo-
ELECTROTHERMAL CAPSULORRHAPHY cations. A magnetic resonance imaging scan performed with intra-articular gadolinium revealed possible capsular attenuation. An open reconstruction was recommended but the patient had surgery with another surgeon who performed the reconstruction arthroscopically. At the time of surgery, a Bankart lesion was identified and fixed. There was thought to be capsular attenuation but it did not require capsular substitution. The patient’s most recent examination found that he currently had a good result (modified ASES score of 89) and was back to his preinjury activity level. For purposes of analysis, his score was not used. Three patients with generalized ligament laxity underwent thermal capsulorrhaphy for multidirectional instability after an asymmetric examination under anesthesia. Two of these patients had an excellent result and 1 had a good result. The patient with ligament laxity and inferior instability had a poor result following the procedure. There were 3 patients with poor results. The first patient had inferior instability as a result of a motor vehicle accident. She had evidence of generalized ligamentous laxity. Preoperatively, she had a sulcus of 3 cm compared with 1.5 cm on the contralateral side. The symptomatic arm required 80° of external rotation to reduce her inferior laxity compared with 55° on the other side. Despite improvement of her subjective stability rating from 2 of 10 to 5 of 10, she still experiences pain and instability when carrying heavy objects. The second patient with a poor result was a 23-yearold man with anterior instability who developed subacromial impingement syndrome 10 months after his instability procedure. He later underwent an arthroscopic subacromial decompression 1 year after his index operation, and currently has unrestricted use of his arm. The third patient with anterior instability and a partial-thickness undersurface rotator cuff tear that was debrided, developed a frozen shoulder requiring arthroscopic capsular release 14 months after her surgery. After the release, the patient had fair use of the arm. During analysis of the outcomes, the modified ASES scores prior to subsequent procedures were used. Complications of capsulorrhaphy may include axillary neuropathy, capsular deficiency, and adhesive capsulitis. There were no instances of axillary neuropathy in the 31 patients with minimum 2-year follow-up in our series. One patient in this series had signs of capsular deficiency postoperatively. However, he also sus-
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tained a traumatic dislocation playing basketball in the early postoperative period. It is likely that the trauma associated with his dislocation contributed to his capsular deficiency. At revision surgery, he was found to have a classical Bankart lesion which was repaired; his capsular insufficiency was not severe enough to require capsular augmentation. His result has been satisfactory following his arthroscopic Bankart repair. Frozen shoulder developed in 1 patient in our series. We were unable to identify any preoperative risk factors, intra-operative technical deviations, or postoperative rehabilitation features that would account for the development of stiffness. This patient did not respond to 14 months of rehabilitation and ultimately required arthroscopic capsular release. She responded well to capsular release, with return of motion, decrease in pain, and lack of recurrent instability.
DISCUSSION Shoulder instability consists of a wide spectrum of clinical and pathologic conditions that range from traumatic unidirectional instability to atraumatic multidirectional instability.20 Recurrent dislocations are often associated with detachment of the glenohumeral capsulolabral complex from the glenoid, humerus, or both. Jobe et al.21 recognized another pattern of instability that was unidirectional but atraumatic in nature. All patients in our series had recurrent glenohumeral subluxation without associated capsulolabral avulsion. In cases of shoulder instability that show increased capsular laxity without associated capsulolabral pathology, the traditional surgical treatments have included open capsular shift for multidirectional instability and open anterior capsulolabral reconstruction for anterior unidirectional instability. The small number of patients with multidirectional instability in this study prevents any definitive conclusions from being formed regarding their treatment. Jobe et al.22 reported their results for 25 overhand athletes with anterior instability who underwent open anterior capsulolabral reconstruction. Seventeen patients (68%) had excellent results and 6 (24%) had good results. Those results appear similar to the results of the 25 patients in this study with unidirectional anterior instability. The patients in this study with unidirectional anterior instability had 16 excellent results (64%) and 3 good results (12%). Capsular plication as a treatment of shoulder instability has been gaining in popularity because of concerns about the complications of thermal energy.
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However, no reports of the results or its complications have been published. Most data reported about thermal capsulorrhaphy have been for multidirectional instability or for a combination of instability patterns. In 1998, Fanton23 found that the success rate in 54 patients who had been treated with radiofrequency-assisted capsulorrhaphy was greater than 90% after 2 years. Two thirds of the patients were treated with thermal capsulorrhaphy alone, and the other one third required supplemental fixation of capsulolabral defects. One patient who presented with multidirectional instability had a recurrent subluxation, which was felt to be secondary to under treatment and an inadequate period of immobilization. The other failure occurred in a patient who had an associated large Hill-Sachs defect. Savoie and Field17 reported satisfactory results after 26 months in 28 of 30 patients with multidirectional instability who underwent thermal capsulorrhaphy and suture plication of the rotator interval. In 3 patients, a small anterosuperior labral tear was discovered and fixed at the time of surgery. They believed that these results were comparable to open and arthroscopic capsular shift techniques. Fitzgerald et al.24 were able to successfully return 23 of 30 patients (76%) with multidirectional instability to full active duty following thermal capsulorrhaphy. However, 7 of the 30 patients were medically discharged from the military because of continued shoulder dysfunction following thermal shrinkage. Anderson et al.25 reported less enthusiastic results for their patients who had undergone thermal capsulorrhaphy. In their series of 80 patients with a variety of instability patterns, thermal capsulorrhaphy either as a primary procedure or as an adjunct to labral repairs resulted in 5 failures. They concluded that thermal shrinkage may be less successful in patients with atraumatic shoulder instability and may not be indicated for all forms of instability, especially in patients who have undergone previous stabilization procedures. In 2003, Noonan et al.26 reported 9 failures in 50 patients (18%) who had undergone thermal capsular shrinkage for a variety of instability patterns. In an attempt to define patients who may be more likely to have early failure after thermal capsulorrhaphy, Anderson et al.27 reviewed the results of 106 patients all with at least 6 months of follow-up. The study found a significantly higher failure rate among patients with a history of more then 2 dislocations or previous surgery. Several other parameters examined, including contact sports, multidirectional instability,
and other procedures performed concurrent with the thermal capsulorrhaphy, did not show significantly higher rates of failure. This study also presents a series of patients with a combination of instability patterns treated with thermal capsulorrhaphy.17,23-27 However, a large group of anterior unidirectional instability patients can be analyzed as a separate subset. The results for all patients are similar to results reported by other authors previously presented. The subgroup of patients with anterior instability also had results similar to those previously reported for open procedures.22 To draw conclusions about the results of thermal capsulorrhaphy compared with other types of open procedures would be difficult because of the lack of patients for other types of instability patterns. A small number of complications did occur in the patients. One patient developed a frozen shoulder and 1 had capsular deficiency. No patient had an axillary nerve injury. Fanton23 has reported axillary neuropathy following thermal capsulorrhaphy. As a means of preventing axillary nerve injury, he recommends decreasing the power setting when in the axillary pouch or avoiding the pouch completely. There is little evidence for understanding how much the power can be decreased and still accomplish appropriate levels of shrinkage. Furthermore, avoiding the pouch would exclude many patients with glenohumeral instability associated with laxity of this capsular region. More work is necessary in order to document the steps necessary to minimize risk to the axillary nerve while allowing thermal treatment of all pathologic capsular regions. The importance of examination under anesthesia to determine the instability pattern is essential to direct the surgery. The ligaments and capsular regions reduced in length in this study were chosen based on a thorough examination under anesthesia that showed side-to-side comparison based on both rotational and translational testing. Only those ligaments and capsular areas that had increased laxity and were consistent with preoperative symptoms were treated in an attempt to restore their normal length.
CONCLUSIONS The role of thermal capsulorrhaphy for the treatment of shoulder instability continues to be defined. The results of this study support its use in a wide range of instability patterns, but especially for patients with unidirectional anterior instability and an intact labrum.
ELECTROTHERMAL CAPSULORRHAPHY REFERENCES 1. Arnoczky SP, Aksan A. Thermal modification of connective tissues: Basic science considerations and clinical implications. J Am Acad Orthop Surg 2000;8:305-313. 2. Hayashi K, Hecht P, Thabit G III, et al. The biologic response to laser thermal modification in an in vivo sheep model. Clin Orthop 2000;373:265-276. 3. Hayashi K, Massa KL, Thabit G III, et al. Histologic evaluation of the glenohumeral joint capsule after the laser-assisted capsular shift procedure for glenohumeral instability. Am J Sports Med 1999;27:162-167. 4. Hayashi K, Thabit G III, Massa KL, et al. The effect of thermal heating on the length and histologic properties of the glenohumeral joint capsule. Am J Sports Med 1997;25:107-112. 5. Hayashi K, Thabit G III, Vailas AC, Bogdanske JJ, Cooley AJ, Markel MD. The effect of nonablative laser energy on joint capsular properties. An in vitro histologic and biochemical study using a rabbit model. Am J Sports Med 1996;24:640646. 6. Hecht P, Hayashi K, Cooley AJ, et al. The thermal effect of monopolar radiofrequency energy on the properties of joint capsule. An in vivo histologic study using a sheep model. Am J Sports Med 1998;26:808-814. 7. Hecht P, Hayashi K, Lu Y, et al. Monopolar radiofrequency energy effects on joint capsular tissue: potential treatment for joint instability. An in vivo mechanical, morphological, and biochemical study using an ovine model. Am J Sports Med 1999;27:761-771. 8. Lopez MJ, Hayashi K, Fanton GS, Thabit G III, Markel MD. The effect of radiofrequency energy on the ultrastructure of joint capsular collagen. Arthroscopy 1998;14:495-501. 9. Lopez MJ, Hayashi K, Vanderby R Jr, Thabit G III, Fanton GS, Markel MD. Effects of monopolar radiofrequency energy on ovine joint capsular mechanical properties. Clin Orthop 2000;374:286-297. 10. Naseef GS III, Foster TE, Trauner K, Solhpour S, Anderson RR, Zarins B. The thermal properties of bovine joint capsule. The basic science of laser- and radiofrequency-induced capsular shrinkage. Am J Sports Med 1997;25:670-674. 11. Osmond C, Hecht P, Hayashi K, et al. Comparative effects of laser and radiofrequency energy on joint capsule. Clin Orthop 2000;375:286-294. 12. Wallace AL, Hollinshead RM, Frank CB. The scientific basis of thermal capsular shrinkage. J Shoulder Elbow Surg 2000; 9:354-360. 13. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic
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treatment of anterior-inferior glenohumeral instability. Two- to five-year follow-up. J Bone Joint Surg Am 2000;82:991-1003. Gartsman GM, Roddey TS, Hammerman SM. Arthroscopic treatment of bidirectional glenohumeral instability: Two- to five-year follow-up. J Shoulder Elbow Surg 2001;10:28-36. Levy O, Wilson M, Williams H, et al. Thermal capsular shrinkage for shoulder instability. Mid-term longitudinal outcome study. J Bone Joint Surg Br 2001;83:640-645. Lyons TR, Griffith PL, Savoie FH III, Field LD. Laser-assisted capsulorrhaphy for multidirectional instability of the shoulder. Arthroscopy 2001;17:25-30. Savoie FH III, Field LD. Thermal versus suture treatment of symptomatic capsular laxity. Clin Sports Med 2000;19:63-75. 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. Gerber C, Werner CM, Macy JC, Jacob HA, Nyffeler RW. Effect of selective capsulorrhaphy on the passive range of motion of the glenohumeral joint. J Bone Joint Surg Am 2003;85:48-55. Thomas SC, Matsen FA IIIO. An approach to the repair of avulsion of the glenohumeral ligaments in the management of traumatic anterior glenohumeral instability. J Bone Joint Surg Am 1989;71:506-513. Jobe FW, Kvitne RS, Giangarra CE. Shoulder pain in the overhand or throwing athlete. The relationship of anterior instability and rotator cuff impingement. Orthop Rev 1989;18: 963-975. Jobe FW, Giangarra CE, Kvitne RS, Glousman RE. Anterior capsulolabral reconstruction of the shoulder in athletes in overhand sports. Am J Sports Med 1991;19:428-434. Fanton GS. Arthroscopic electrothermal surgery of the shoulder. Oper Tech Sports Med 1998;6:139-146. Fitzgerald BT, Watson BT, Lapoint JM. The use of thermal capsulorrhaphy in the treatment of multidirectional instability. J Shoulder Elbow Surg 2002;11:108-113. Anderson SP, McCarty EC, Warren RF. Thermal capsulorrhaphy: Where are we now? Sports Med Arthrosc Rev 1999;7: 117-127. Noonan TJ, Tokish JM, Briggs KK, Hawkins RJ. Laserassisted thermal capsulorrhaphy. Arthroscopy 2003;19:815819. Anderson K, Warren RF, Altchek DW, Craig EV, O’Brien SJ. Risk factors for early failure after thermal capsulorrhaphy. Am J Sports Med 2002;30:103-107.
Purpose: The purpose of this study was to review the results of a relatively homogenous group of patients with glenohumeral subluxation without labral pathology who were treated with an electrothermal capsulorrhaphy procedure. Type of Study: Case series without controls. Methods: From 1997 to 1998, 42 patients underwent electrothermal capsulorrhaphy using a monopolar radiofrequency probe (Oratec Interventions, Menlo Park, CA). Patients with prior capsular repairs, labral pathology that required repair, or capsular avulsion injuries were excluded from the study. Thirty-one patients met the inclusion criteria. Patients had a minimum of 2 years of follow-up (mean, 25 months), and a mean age of 25 years (range, 16 to 38 years). All of the patients had previously failed conservative treatment. There were 25 patients with unidirectional anterior instability, 2 patients with unidirectional inferior instability, 1 patient with unidirectional posterior instability, and 3 patients with multidirectional instability. The patients were assessed using a modified American Shoulder and Elbow Surgeons (ASES) score that examined pain (30 points), function (60 points), and patient satisfaction (10 points). In addition, subjective stability was assessed using a 10-point scale. Results: The average modified ASES score increased to 88 points from 56 preoperatively (P ⬍ .01). The average subjective stability scale increased to 8.5 from 4.4 preoperatively (P ⬍ .01). Nineteen patients (61%) had an excellent result, 4 (13%) had a good result, 5 (16%) had a fair result, and 3 (10%) had a poor result; 22 of 26 patients who participated in sports were able to return to their preinjury level of play. The subset of patients with isolated anterior instability had results similar to the overall group. There were no instances of axillary neuritis or other neurologic injury. Conclusions: In carefully selected patients with shoulder instability, including unidirectional anterior instability without associated labral pathology, electrothermal capsulorrhaphy was effective and had few complications. Level of Evidence: Level IV, case series without controls. Key Words: Thermal capsulorrhaphy— Shoulder—Instability.
T
he thermal effects of laser or radiofrequency energy on collagen are well known.1-12 The clinical applications of thermal energy in the man-
From the Departments of Orthopaedic Surgery, the Hospitals of the University of Pennsylvania (K.L.W., C.L.G., G.L.Y., M.R., G.R.W.), Philadelphia, Pennsylvania; and the Cleveland Clinic Foundation (J.P.I.), Cleveland, Ohio, U.S.A. Address correspondence and reprint requests to Gerald R. Williams, Jr., M.D., Penn Musculoskeletal Institute, One Cupp Pavilion, 39th and Market Sts, Philadelphia, PA 19104, U.S.A. E-mail: [email protected] © 2005 by the Arthroscopy Association of North America 0749-8063/05/2108-4250$30.00/0 doi:10.1016/j.arthro.2005.05.003
agement of glenohumeral instability, however, are still evolving. Both laser and radiofrequency energy have been used in isolation or as an adjunct to other stabilization procedures to treat glenohumeral instability.13-17 The reported results of these procedures are difficult to interpret because of potential differences in patient selection criteria, method of energy application, and type of instability. The purpose of this study was to review the clinical results of electrothermal capsulorrhaphy using one method of energy delivery (monopolar radiofrequency) in a selected group of patients with glenohumeral subluxation without labral tears or prior labral repair. The hypothesis is that, in this group of instability
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patients, thermal capsulorrhaphy is an effective treatment. METHODS Between April 1997 and November 1998, 42 patients underwent thermal capsulorrhaphy using a monopolar radiofrequency probe (Oratec Interventions, Menlo Park, CA). All patients had failed conservative treatment that included a minimum of 3 months of therapeutic exercises. Patients with multidirectional instability or generalized laxity had a minimum of 12 months of conservative therapy. Patients with prior stability procedures, including capsular procedures, labral pathology that required arthroscopic or open repair, or humeral capsular avulsion injuries, were excluded from the analysis. Five shoulders had each undergone 1 previous shoulder procedure. These included 2 diagnostic arthroscopies with minor labral debridements, 1 diagnostic arthroscopy with minor rotator cuff debridement, 1 arthroscopic acromioplasty, and 1 arthroscopic distal clavicle resection. None of the patients had any prior capsulolabral repairs or reconstructions and none had labral detachment requiring repair. Patients with previous labral debridement were included because this was not considered a stabilization procedure. Thirty-five patients satisfied our inclusion criteria with a minimum of 2 years of follow-up. Four patients were lost to follow-up and were excluded from the study. The remaining 31 patients form the basis of our study. Preoperative and postoperative evaluation included history, physical examination, and completion of a patient self-assessment questionnaire. Results were graded using a modified American Shoulder and Elbow Surgeons (ASES) shoulder score (100 points) based on pain (30 points), function (60 points), and patient satisfaction (10 points). An excellent result was identified if the modified ASES score was 90 to 100 points, a good result required a modified ASES score of 80 to 89, a fair result required a modified ASES score of 70 to 79, and a poor result occurred if the modified ASES score was less than 70 points. In addition, patients rated their stability using a 10-point scale. Patients were also questioned about their level of athletic performance, endurance, and stability. The average age of our patients was 25 years (range, 16 to 38 years). There were 23 male and 8 female patients. Mean follow-up was 25 months (range, 24 to 30 months). The dominant extremity was involved in 17 patients. The time from the initial complaint of shoulder dysfunction to surgical inter-
vention averaged 27 months (range, 4 to 96 months). Twenty-nine patients (91%) had recurrent glenohumeral subluxation with no history of dislocation. Subluxation is defined as a feeling of instability by the patient without a documented frank glenohumeral dislocation. Two patients had sustained a single dislocation. Twelve patients were recreational athletes, 5 were high-school athletes, and 9 were college athletes. Thirteen (50%) of these patients were involved in sports requiring overhead use of the limb such as baseball pitching, tennis, volleyball, and swimming. Twentytwo patients recalled a specific injury; 14 sports injuries, 3 motor vehicle accidents, 1 fall from a height of 6 feet, 1 blow to the anterior aspect of his shoulder, and 3 heavy lifting injuries. Three patients had Workers’ Compensation claims. Nine patients recalled no specific injury to their shoulder and attributed their symptoms to repetitive overhead athletic activity such as throwing, tennis serving, swimming, or volleyball spiking. An examination under anesthesia was performed to quantify range of motion, and humeral head translation. Quantification of range of motion included maximal elevation in the scapular plane, external rotation with the arm at the side, external rotation with the arm at 90° of elevation in the scapular plane, and internal rotation with the arm at 90° of elevation in the scapular plane. Anterior translation was tested in neutral, 45°, and 90° of abduction, similar to that described by Altchek et al.18 For posterior instability, the amount of posterior translation was determined in neutral, 45°, and 90° of abduction. Inferior translation was examined with the arm at the side and was observed as the arm was externally rotated. Inferior translation that remained despite external rotation indicated rotator interval pathology The effect of humeral rotation was also observed during translational testing. Inferior translation was tested in varying amounts of external rotation from 0° to maximal external rotation. Anterior translation was tested in varying degrees of external rotation from neutral to maximal rotation in all 3 positions of abduction. Posterior translation was tested in varying degrees of internal rotation from neutral to maximal internal rotation in all 3 positions of abduction. Range of motion and translation were compared with the opposite, normal side. The decision to perform thermal capsulorrhaphy was based on the presence of a side-to-side difference in translation and rotation.19 Increased external rotation with the arm abducted to 90° indicated pathology
ELECTROTHERMAL CAPSULORRHAPHY of the anterior inferior glenohumeral ligament. Increased internal rotation in the abducted position indicated pathology of the posterior inferior glenohumeral ligament. A side-to-side difference of external rotation with the arm at the side indicates rotator interval pathology. Surgery was then aimed toward shortening the elongated structures as directed by the examination under anesthesia. Surgical Technique All cases were performed with patients in the beach-chair position. A complete diagnostic arthroscopy was performed to rule out any labral avulsions. The portals used for placement of the arthroscopic radiofrequency probe varied with the region(s) of the glenohumeral capsule requiring shrinking. For shrinkage of the rotator interval, anterior capsule, and the anterior portion of the inferior glenohumeral ligament, an anterior portal that penetrated the joint through the rotator interval immediately superior to the subscapularis tendon was used. During shrinkage of the posterior capsule and the posterior portion of the inferior glenohumeral ligament, a posterior portal was used. The region(s) of the capsule undergoing shrinkage was determined based on the preoperative history and concordant physical examination as well as the results of the examination under anesthesia. The rotator interval was treated if history of inferior instability was confirmed by the following findings during examination under anesthesia: increased external rotation with the arm at the side, increased inferior translation with the arm at the side, and an increase in the amount of external rotation required to reduce the sulcus sign compared with the other arm. The anterior capsule and the anterior portion of the inferior glenohumeral ligament were treated if the patient exhibited a history of anterior instability combined with the following findings under anesthesia: increased external rotation with the arm at 90° abduction in the plane of the scapula, increased anterior translation with the arm at 45° and 90° of scapular plane elevation, and increased external rotation required to decrease translation compared with the normal side. The posterior capsule was treated if the patient exhibited signs and symptoms of posterior instability and an examination under anesthesia with the following: increased internal rotation with the arm at 90° of scapular plane abduction, increased posterior translation with the arm in neutral rotation and 45° and 90° of scapular plane abduction, and an increased amount of internal rotation required
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to decrease the posterior translation compared with the normal side. The radiofrequency energy was applied using an arthroscopic probe attached to a first-generation Oratec monopolar radiofrequency generator preset at 40 W of power and 65°C. As mentioned earlier, the axillary recess was treated only when there was evidence of increased external rotation or internal rotation with the arm at 90° of elevation. The region of the capsule requiring shrinking was treated with the radiofrequency probe by passing the tip of the probe over the capsule in an inferior to superior direction starting immediately distal to the labrum. The next pass was made parallel to the first one, with 5 mm of normal capsule between the 2 stripes. This was continued laterally until the humeral attachment was encountered. This resulted in 3 or 4 stripes in all areas of the capsule treated. Postoperative Rehabilitation Aftercare was individualized according to the region(s) of the capsule undergoing shrinkage. Patients with isolated anterior instability were placed in a sling for 3 weeks. Pendulum exercises were begun at 3 weeks, use of the arm for activities of daily living was allowed at this time as well. Six weeks postoperatively, passive mobilization of the joint was instituted, with a limitation of no external rotation stretching with the arm at 90° of elevation in the scapular plane. Active use of the arm was allowed with the same restrictions as indicated for passive therapy at 6 weeks. External rotation stretching in the abducted position was instituted 10 to 12 weeks postoperatively if external rotation in this position was lacking 15° or more than the opposite shoulder. Rotator cuff, deltoid, and scapular strengthening exercises were also instituted at 6 weeks postoperatively. Return to overhead sport was not allowed until 6 months postoperatively. Resumption of preinjury sport level was deferred until 6 to 9 months postoperatively. Patients with isolated inferior instability were prescribed a sling for 6 weeks. Pendulum exercises were instituted at 4 to 6 weeks postoperatively. Passive mobilization was instituted 6 weeks postoperatively, with a limitation of no external rotation stretching. Active motion for activities of daily living were allowed at 6 weeks. External rotation stretching with the arm at the side was instituted 10 to 12 weeks postoperatively if external rotation loss with the arm at the side, compared with the normal side, was greater than 15°. Rotator cuff, deltoid, and scapular strengthening
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exercises were instituted 6 weeks postoperatively. Return to full activity was allowed 6 to 9 months postoperatively. After treatment for multidirectional or posterior instability, postoperative immobilization consisted of a brace with the arm in approximately 20° of abduction and 30° of external rotation for 6 weeks. After brace removal, the patients were asked to use their arm within their limits of pain for activities of daily living that did not involve lifting and to begin pendulum exercises. Passive stretching was instituted 10 to 12 weeks postoperatively if motion loss in any direction, compared with the normal side, was greater than 15°. Rotator cuff, deltoid, and scapular strengthening exercises were instituted 6 weeks postoperatively. Return to sport or full activity was withheld until 6 to 9 months postoperatively. Statistical Analysis Preoperative and postoperative modified ASES scores were compared using a paired t test. In those patients who required another operation, the modified ASES score before the second procedure was used. The preoperative and postoperative instability scores were compared using the nonparametric Wilcoxon rank-sum test. All statistical analysis was performed using Intercooled Stata 5.0 (Stata, College Station, TX). RESULTS Thirty-one patients underwent selective thermal capsulorrhaphy following asymmetric examination under anesthesia. There were 25 patients with unidirectional anterior instability, 2 patients with inferior instability, 1 patient with posterior instability, and 3 patients with multidirectional instability (1 inferior/ posterior, and 2 anterior/posterior). The 25 patients with unidirectional anterior instability underwent shrinkage of the anterior capsule and the anterior portion of the inferior glenohumeral ligament. The 2 patients with isolated inferior instability underwent shrinkage of the rotator interval capsule. The patient with unidirectional posterior instability underwent shrinkage of the posterior capsule and posterior portion of the inferior glenohumeral ligament. The patient with inferior and posterior instability underwent shrinkage of the rotator interval capsule, the posterior capsule, and the posterior portion of the inferior glenohumeral ligament. The 2 patients with anterior and posterior instability underwent shrinkage of the ante-
TABLE 1. Results of Patients Who Underwent Electrothermal Capsulorrhaphy
Modified ASES score Stability rating
Preoperative Scores
Postoperative Scores
P Values
56 (12–86) 4.4 (0–10)
88 (46–88) 8.5 (0–10)
P ⬍ .0001 P ⬍ .0001
rior capsule, the anterior portion of the inferior glenohumeral ligament, the posterior capsule, and the posterior portion of the inferior glenohumeral ligament. Four patients had generalized ligamentous laxity with hyperextension of the metacarpophalangeal joints, hyperabduction of the thumb, and recurvatum of the elbows. One patient had unidirectional inferior instability and 3 others had multidirectional instability patterns. The average modified ASES score increased to 88 points (range, 46-100) from 56 preoperatively (range, 12-86; P ⬍ .0001). The average subjective stability scale increased to 8.5 (range, 0-10) from 4.4 preoperatively (range, 0-10; P ⬍ .0001) (Table 1). Nineteen patients (61%) had an excellent result, 4 (13%) had a good result, 5 (16%) had a fair result, and 3 (10%) had a poor result of all those treated. When analyzing the 25 patients with isolated anterior instability as a separate subset of patients, 16 patients (64%) had excellent results, 3 patients (12%) had good results, 5 patients (20%) had fair results, and 1 patient (4%) had a poor result. Both patients with bidirectional anteroposterior instability had excellent results. One of the 2 patients with isolated inferior instability had an excellent result; the other patient had a poor result, with a subjective stability score of 5 of 10 compared with 2 of 10 preoperatively. The patient with bidirectional inferior/ posterior instability had a good result. The only patient with isolated posterior instability had a poor result. Twenty-two (85%) of 26 patients who participated in recreational or competitive athletics reported return to their preinjury level of function in their respective sports. One patient with anterior subluxation and an early good result sustained a traumatic anterior dislocation while playing basketball 2 months postoperatively, against our advice. Before his thermal capsulorrhaphy, he had sustained an anterior subluxation without dislocation as a result of a motor vehicle accident. Despite aggressive rehabilitation after a brief period of immobilization, he suffered recurrent shoulder dislo-
ELECTROTHERMAL CAPSULORRHAPHY cations. A magnetic resonance imaging scan performed with intra-articular gadolinium revealed possible capsular attenuation. An open reconstruction was recommended but the patient had surgery with another surgeon who performed the reconstruction arthroscopically. At the time of surgery, a Bankart lesion was identified and fixed. There was thought to be capsular attenuation but it did not require capsular substitution. The patient’s most recent examination found that he currently had a good result (modified ASES score of 89) and was back to his preinjury activity level. For purposes of analysis, his score was not used. Three patients with generalized ligament laxity underwent thermal capsulorrhaphy for multidirectional instability after an asymmetric examination under anesthesia. Two of these patients had an excellent result and 1 had a good result. The patient with ligament laxity and inferior instability had a poor result following the procedure. There were 3 patients with poor results. The first patient had inferior instability as a result of a motor vehicle accident. She had evidence of generalized ligamentous laxity. Preoperatively, she had a sulcus of 3 cm compared with 1.5 cm on the contralateral side. The symptomatic arm required 80° of external rotation to reduce her inferior laxity compared with 55° on the other side. Despite improvement of her subjective stability rating from 2 of 10 to 5 of 10, she still experiences pain and instability when carrying heavy objects. The second patient with a poor result was a 23-yearold man with anterior instability who developed subacromial impingement syndrome 10 months after his instability procedure. He later underwent an arthroscopic subacromial decompression 1 year after his index operation, and currently has unrestricted use of his arm. The third patient with anterior instability and a partial-thickness undersurface rotator cuff tear that was debrided, developed a frozen shoulder requiring arthroscopic capsular release 14 months after her surgery. After the release, the patient had fair use of the arm. During analysis of the outcomes, the modified ASES scores prior to subsequent procedures were used. Complications of capsulorrhaphy may include axillary neuropathy, capsular deficiency, and adhesive capsulitis. There were no instances of axillary neuropathy in the 31 patients with minimum 2-year follow-up in our series. One patient in this series had signs of capsular deficiency postoperatively. However, he also sus-
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tained a traumatic dislocation playing basketball in the early postoperative period. It is likely that the trauma associated with his dislocation contributed to his capsular deficiency. At revision surgery, he was found to have a classical Bankart lesion which was repaired; his capsular insufficiency was not severe enough to require capsular augmentation. His result has been satisfactory following his arthroscopic Bankart repair. Frozen shoulder developed in 1 patient in our series. We were unable to identify any preoperative risk factors, intra-operative technical deviations, or postoperative rehabilitation features that would account for the development of stiffness. This patient did not respond to 14 months of rehabilitation and ultimately required arthroscopic capsular release. She responded well to capsular release, with return of motion, decrease in pain, and lack of recurrent instability.
DISCUSSION Shoulder instability consists of a wide spectrum of clinical and pathologic conditions that range from traumatic unidirectional instability to atraumatic multidirectional instability.20 Recurrent dislocations are often associated with detachment of the glenohumeral capsulolabral complex from the glenoid, humerus, or both. Jobe et al.21 recognized another pattern of instability that was unidirectional but atraumatic in nature. All patients in our series had recurrent glenohumeral subluxation without associated capsulolabral avulsion. In cases of shoulder instability that show increased capsular laxity without associated capsulolabral pathology, the traditional surgical treatments have included open capsular shift for multidirectional instability and open anterior capsulolabral reconstruction for anterior unidirectional instability. The small number of patients with multidirectional instability in this study prevents any definitive conclusions from being formed regarding their treatment. Jobe et al.22 reported their results for 25 overhand athletes with anterior instability who underwent open anterior capsulolabral reconstruction. Seventeen patients (68%) had excellent results and 6 (24%) had good results. Those results appear similar to the results of the 25 patients in this study with unidirectional anterior instability. The patients in this study with unidirectional anterior instability had 16 excellent results (64%) and 3 good results (12%). Capsular plication as a treatment of shoulder instability has been gaining in popularity because of concerns about the complications of thermal energy.
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However, no reports of the results or its complications have been published. Most data reported about thermal capsulorrhaphy have been for multidirectional instability or for a combination of instability patterns. In 1998, Fanton23 found that the success rate in 54 patients who had been treated with radiofrequency-assisted capsulorrhaphy was greater than 90% after 2 years. Two thirds of the patients were treated with thermal capsulorrhaphy alone, and the other one third required supplemental fixation of capsulolabral defects. One patient who presented with multidirectional instability had a recurrent subluxation, which was felt to be secondary to under treatment and an inadequate period of immobilization. The other failure occurred in a patient who had an associated large Hill-Sachs defect. Savoie and Field17 reported satisfactory results after 26 months in 28 of 30 patients with multidirectional instability who underwent thermal capsulorrhaphy and suture plication of the rotator interval. In 3 patients, a small anterosuperior labral tear was discovered and fixed at the time of surgery. They believed that these results were comparable to open and arthroscopic capsular shift techniques. Fitzgerald et al.24 were able to successfully return 23 of 30 patients (76%) with multidirectional instability to full active duty following thermal capsulorrhaphy. However, 7 of the 30 patients were medically discharged from the military because of continued shoulder dysfunction following thermal shrinkage. Anderson et al.25 reported less enthusiastic results for their patients who had undergone thermal capsulorrhaphy. In their series of 80 patients with a variety of instability patterns, thermal capsulorrhaphy either as a primary procedure or as an adjunct to labral repairs resulted in 5 failures. They concluded that thermal shrinkage may be less successful in patients with atraumatic shoulder instability and may not be indicated for all forms of instability, especially in patients who have undergone previous stabilization procedures. In 2003, Noonan et al.26 reported 9 failures in 50 patients (18%) who had undergone thermal capsular shrinkage for a variety of instability patterns. In an attempt to define patients who may be more likely to have early failure after thermal capsulorrhaphy, Anderson et al.27 reviewed the results of 106 patients all with at least 6 months of follow-up. The study found a significantly higher failure rate among patients with a history of more then 2 dislocations or previous surgery. Several other parameters examined, including contact sports, multidirectional instability,
and other procedures performed concurrent with the thermal capsulorrhaphy, did not show significantly higher rates of failure. This study also presents a series of patients with a combination of instability patterns treated with thermal capsulorrhaphy.17,23-27 However, a large group of anterior unidirectional instability patients can be analyzed as a separate subset. The results for all patients are similar to results reported by other authors previously presented. The subgroup of patients with anterior instability also had results similar to those previously reported for open procedures.22 To draw conclusions about the results of thermal capsulorrhaphy compared with other types of open procedures would be difficult because of the lack of patients for other types of instability patterns. A small number of complications did occur in the patients. One patient developed a frozen shoulder and 1 had capsular deficiency. No patient had an axillary nerve injury. Fanton23 has reported axillary neuropathy following thermal capsulorrhaphy. As a means of preventing axillary nerve injury, he recommends decreasing the power setting when in the axillary pouch or avoiding the pouch completely. There is little evidence for understanding how much the power can be decreased and still accomplish appropriate levels of shrinkage. Furthermore, avoiding the pouch would exclude many patients with glenohumeral instability associated with laxity of this capsular region. More work is necessary in order to document the steps necessary to minimize risk to the axillary nerve while allowing thermal treatment of all pathologic capsular regions. The importance of examination under anesthesia to determine the instability pattern is essential to direct the surgery. The ligaments and capsular regions reduced in length in this study were chosen based on a thorough examination under anesthesia that showed side-to-side comparison based on both rotational and translational testing. Only those ligaments and capsular areas that had increased laxity and were consistent with preoperative symptoms were treated in an attempt to restore their normal length.
CONCLUSIONS The role of thermal capsulorrhaphy for the treatment of shoulder instability continues to be defined. The results of this study support its use in a wide range of instability patterns, but especially for patients with unidirectional anterior instability and an intact labrum.
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