Arthroscopic Treatment of Multidirectional Shoulder Instability
Arthroscopic Treatment of Multidirectional Shoulder Instability
DEFINITION
Neer and Foster20 described the concept of multidirectional instability (MDI) of the shoulder in detail in 1980.
This established the difference between unidirectional instability and global laxity of the capsule inferiorly, posteriorly, and anteriorly.
Subjective complaints of pain and global shoulder instability
Subluxation or dislocation from traumatic, microtraumatic, or atraumatic injury
ANATOMY
Stability of the shoulder relies on dynamic and static restraints Static restraints
Inferior glenohumeral ligament
Anterior band resists anterior translation in 90 degrees of abduction and external rotation Posterior band resists posterior translation in forward flexion, adduction, and internal rotation
Middle glenohumeral ligament
Resists anterior translation in 45 degrees of abduction Superior glenohumeral ligament
Resists posterior and inferior translation with arm at side Rotator interval/coracohumeral ligament
Resists posterior and inferior translation with arm at side
Dynamic restraints
Rotator cuff muscles Deltoid
Effects of concavity and compression
Shoulder instability has been found to be a result of several pathologic processes:
Capsular laxity
Labral detachment/Bankart lesion Rotator interval defects
Bony defects of humeral head (Hill-Sachs lesion) or glenoid
PATHOGENESIS
Typically, there is not a history of a traumatic shoulder dislocation, but there may be the inciting event. Most commonly, the instability is due to microtrauma resulting in global capsular laxity. There may be a history of recurrent dislocations or repetitive subluxation events. This may occur in overhead athletes such as swimmers and volleyball players.
Young active patients Pain
Complaints of shoulder shifting/subluxation Difficulty with overhead activity
Inability to do sports
Instability while sleeping/night pain Trouble with activities of daily living Episodes of “dead arm” sensation Failed prior attempts at physical therapy
NATURAL HISTORY
Unable to change static restraints
Stability can be achieved by restoring neuromuscular control through rehabilitation.
Recurrent dislocations may lead to Hill-Sachs lesions, glenoid erosion, and/or chondral injury, which may predispose to early degenerative arthritis of the glenohumeral joint.
Recurrent instability affecting daily activities despite formal physical therapy generally requires surgical treatment.
PHYSICAL FINDINGS
Infrequent atrophy Symmetric range of motion
Possible scapulothoracic winging/scapular dyskinesis Scapular depression
Normal strength testing
Possible core weakness Evaluation for ligamentous laxity
Frequently positive for generalized ligamentous laxity Evaluation for impingement
Stability testing
Positive increased load and shift test for anterior and posterior translation
Positive sulcus sign (both in neutral and external rotation) for inferior translation
If sulcus sign graded as 3+ that remains 2+ in external rotation is pathognomonic for MDI—rotator interval lesion.
Evaluation of ligamentous laxity (Beighton scale) Specific tests which may or may not be positive
Apprehension test Relocation test O'Brien sign Mayo shear test Jerk test
Kim test Circumduction test Speed test
IMAGING AND OTHER DIAGNOSTIC STUDIES
Plain radiographs
Anteroposterior view
Axillary lateral or West Point axillary view Outlet view
Stryker notch view
Evaluate for
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Hill-Sachs or reverse Hill-Sachs lesion Glenoid pathology
Bony humeral avulsion of the glenohumeral ligaments (HAGL)
Magnetic resonance arthrogram (MRA)
Evaluate for
Capsular laxity Labral pathology HAGL
Biceps tendon pathology Rotator cuff lesions (rare)
Computed tomography (CT)
Evaluate for
Proximal humeral/glenoid bony pathology
NONOPERATIVE TREATMENT
In many cases with patients with atraumatic MDI, the proper neuromuscular control of dynamic glenohumeral stability has been lost.
The goal is to restore shoulder function through training and exercise.
Patients with loose shoulders may not necessarily be unstable as evidenced by examining the contralateral asymptomatic shoulder in patients with symptomatic MDI.
The mainstay of treatment is nonoperative, with attempts to achieve stability using scapular, core, and glenohumeral (rotator cuff) strengthening exercises.
SURGICAL MANAGEMENT
Indications
Patients who have attempted a (or several) dedicated program(s) of physical therapy, have functional problems, and remain unstable may then be candidates for surgical treatment.
History of MDI with sustained fractures of the glenoid or humeral head with a dislocation generally require surgical treatment.
Significant defects in the humeral head associated with multiple dislocations consistent with engaging Hill-Sachs lesions may require earlier surgical treatment.
Glenoid erosion or lip fractures, if significant, can also necessitate surgical intervention if associated with recurrent instability.
Contraindications
Patients with voluntary or habitual instability
Patients who have not attempted a formal physiotherapy program should avoid initial surgical treatment. Any patient unable or unwilling to comply with the postoperative rehabilitation regimen
Preoperative Planning
Patient education is critical in planning surgical treatment for the patient with an unstable shoulder.
The patients should have failed a trial at nonoperative treatment and have persistent instability with functional deficits.
The goal of surgical treatment is to reduce capsular volume and restore glenoid concavity with capsulolabral augmentation.
By decreasing capsular volume, range of motion may be decreased as a result.
It is important to discuss this possibility with the patient as some more active athletic patients such as throwers, gymnasts, swimmers, and volleyball players may not tolerate losses of motion to maintain participation in their sport.
Additional risks and benefits should be discussed including the risk of infection, recurrence of instability, pain,
neurovascular injury, persistent functional limitations, and implant complications.
The surgical planning continues with the evaluation under anesthesia and diagnostic arthroscopy.
This may alter the plan to include any combination of the following: capsular plication (anterior, posterior, and/or inferior), rotator interval closure, anterior/posterior labral repair, superior labrum anterior posterior repair, biceps tenodesis/tenotomy, and possible conversion to an open capsular shift.
If sulcus sign remains similar in external rotation, then may consider rotator interval closure
Anesthesia and Positioning
The procedure can be performed under interscalene block or general endotracheal anesthesia with an interscalene block for postoperative pain control.
The patient can then be placed in the lateral decubitus position with the affected shoulder positioned superior.
An inflatable beanbag holds the patient in position.
Foam cushions are placed to protect the peroneal nerve at the neck of the fibula on the down leg. An axillary roll is placed.
The operating table is placed in a slight reverse Trendelenburg position.
The full upper extremity is prepped to the level of the sternum anteriorly and the medial border of the scapula posteriorly.
The operative shoulder is placed in 10 pounds of traction and is positioned in 45 degrees of abduction and 20 degrees of forward flexion.
Alternatively, the beach-chair position can be used. In our experience, this position gives us limited exposure of the posterior inferior capsule.
The head of the bed is raised to approximately 70 degrees with the affected shoulder off the side of the bed with support medial to the scapula.
The head should be well supported and all bony prominences padded.
The entire arm, shoulder, and trapezial region are prepped into the surgical field.
A pneumatic arm holder can be used to position the arm to aid in visualization both anteriorly and posteriorly.
Landmarks/Portals
The bony landmarks, including the acromion, distal clavicle, acromioclavicular joint, and coracoid process, are demarcated with a marking pen.
Following prepping and draping, the glenohumeral joint is injected with 50 mL of sterile saline through an 18-gauge spinal needle to inflate the joint.
A posterior portal can be established 3 cm distal (lower) and 1 cm medial (humeral) to the posterolateral corner of the acromion to allow access to the rim of the posterior glenoid
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for anchor placement in the event a posterior labral or capsular repair is necessary.
A superior-anterior portal is then established in the rotator interval via an outside-in technique using a spinal needle. Care should be taken using a spinal needle to verify that a low anterior inferior 5 o'clock anchor can
be placed through a second inferior anterior portal. When using two anterior portals, the superior portal should be placed “high” in the interval to make room for the second “low” portal.
If a second anterior portal is desired, it is created using a spinal needle at the level just superior to the subscapularis tendon lateral to the coracoid and a minimum of 1 cm inferior to the anterior portal.
Examination under Anesthesia/Diagnostic Arthroscopy
The examination under anesthesia is performed on a firm surface with the scapula relatively fixed and the humeral head free to rotate.
A “load and shift” maneuver, as described by Murrell and Warren,19 is performed with the patient supine.
The arm is held in 90 degrees of abduction and neutral rotation while an anterior or posterior force is applied in an attempt to translate the humeral head over the anterior or posterior glenoid.
A “sulcus sign” is performed with the arm adducted and in neutral rotation to assess whether the instability has an inferior component.
A 3+ sulcus sign that remains 2+ or greater in external rotation is considered pathognomonic for MDI.
Testing is completed on both the affected and unaffected shoulders and differences between the two are documented.
Diagnostic arthroscopy of the glenohumeral joint
The labrum, capsule, biceps tendon, subscapularis, rotator interval, rotator cuff, and articular surfaces are visualized in systematic fashion.
This ensures that no associated lesions will be overlooked.
Lesions typically seen in MDI include the following:
Patulous inferior capsule
Labral tears (FIG 1) or fraying and splitting Widening of the rotator interval
Articular partial-thickness rotator cuff tears
After viewing the glenohumeral joint from the posterior portal, the arthroscope is switched to the anterior portal to allow improved visualization of the posterior capsule and labrum.
A switching stick can then be used in replacing the posterior cannula with a 7.0- to 8.25-mm distally threaded or fully threaded clear cannula, thus allowing passage of an arthroscopic probe and other instruments through the clear cannula to explore the posterior labrum for evidence of tears.
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FIG 1 • Labral tear.
TECHNIQUES
Arthroscopic techniques have evolved from capsular shift via transglenoid sutures, Bankart repair and shift with biodegradable tacks or suture anchors, thermal capsulorraphy, rotator interval repair, and capsular plication.
Our current method of treatment for patients with multidirectional shoulder instability who have failed nonoperative attempts is to perform an arthroscopic capsular shift by reducing capsular volume using
capsular plication with a multipleated repair.26
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Specific Steps
Preparation for Repair
The arthroscope that remains in the posterior portal and the anterior portals serve as the working portal for the anterior repair and vice versa for the posterior repair.
The side (anterior or posterior) that is least unstable is fixed first. For example, if posterior instability is the most severe direction, the anterior and inferior sides are fixed first and the posterior capsule and labrum is addressed last.
An arthroscopic rasp or chisel is used to mobilize any torn labrum from the glenoid rim (TECH FIG 1A).
A motorized synovial shaver or meniscal rasp is used to abrade the capsule adjacent to a labral tear and to débride and decorticate the glenoid rim to achieve a bleeding surface for capsular plication (TECH FIG 1B).
Capsular Plication (TECH FIG 2A)
A 3.0-mm Bio-SutureTak anchor loaded with no. 2 FiberWire (Arthrex, Inc., Naples, FL) is placed in the 5 o'clock position (right shoulder) for the anterior repair and 7 o'clock position for the posterior repair and the sutures brought out through the working portal (TECH FIG 2B).
The anchor can be placed through the cannula or percutaneously.
A soft tissue penetrator (Spectrum Suture Hook, Linvatec, Corp., Largo, FL) or crescent suture passer is passed through the labrum directly adjacent to the anchor and the inferior FiberWire on the anchor is pulled through the labrum (TECH FIG 2C).
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TECH FIG 1 • A. Rasping capsule to stimulate healing after capsular plication. B. Capsular/glenoid abrasion with a motorized shaver.
The penetrator is then used to pierce the inferior capsule in the most anterior/inferior (5 o'clock anchor) and lateral point or posterior/inferior (7 o'clock anchor) and lateral point.
Once through the capsule, a no. 1 PDS (Ethicon, Johnson & Johnson, Somerville, New Jersey) is shuttled into the joint and the penetrator is removed (TECH FIG 2D).
A suture grasper is then used to grab both the passed PDS and the labral suture and pull them out of the same portal or the working portal if two portals are used.
The PDS is then tied with a simple knot to the FiberWire, and the PDS is then used to shuttle the working suture through the inferior tuck of capsule (TECH FIG 2E).
This simple process is repeated while moving superiorly up the capsule until adequate capsular tension
was restored (TECH FIG 2F).23 This can be done multiple times until adequate capsular tension is achieved with each suture.
The suture is checked to ensure it will still slide, then a locking, sliding knot backed with three half-hitches is tied. The remaining suture is then cut (TECH FIG 2G).
This is begun posteriorly and inferiorly (7 o'clock anchor), working posterior with additional anchors as necessary (TECH FIG 2H), and then anterior and inferiorly (5 o'clock anchor) working up anterior, again using additional anchors as necessary (TECH FIG 2I). This would be the case if anterior instability is the most severe direction. If posterior instability is predominant, then the plication would begin anteriorly and inferiorly and then finish posteriorly.
The completed capsular plication reduces volume and improves stability (TECH FIG 2J).
Arthroscopic Knot Tying
The preferred sliding, locking knot is the “Weston” knot, but there are a number of arthroscopic knot-tying techniques that work well.
What is most important is that the surgeon be familiar with the knot used and be skilled in its use.
The posterior braided suture exiting through the capsule is threaded through a knot pusher and the end is secured with a hemostat.
This suture serves as the post, which in effect will advance the capsule and labrum to the glenoid rim when the knot is tightened.
The knot should be secured posteriorly on the capsule and not on the rim of the glenoid to prevent humeral head abrasion from the knot.
Each half-hitch must be completely seated before the next halfhitch is thrown.
Placing tension on the nonpost suture and advancing the knot pusher “past point” will lock the Weston knot.
A total of three alternating half-hitches are placed to secure the Weston knot. This knot has been found biomechanically similar to an open square knot.6
Rotator Interval Closure
In the setting of MDI, the rotator interval may not require closure if a capsular shift is performed both anteriorly and posteriorly to bring up the entire axillary pouch.
However, if rotator interval closure is required (defined by a 2+ or greater sulcus sign that does not improve in external rotation), it is viewed with the arthroscope in the posterior portal.24
A crescent suture passer is advanced from the anterior portal through the anterior capsule just above the superior border of the subscapularis tendon 1 cm lateral to the glenoid.
It is then passed through the middle glenohumeral ligament at the inferior border of the rotator interval. This makes up the inferior aspect of the rotator interval closure.
A no. 0 PDS suture is then fed into the joint and retrieved with a penetrator through the superior glenohumeral ligament.
The PDS suture is then withdrawn out the anterior cannula and exchanged for a no. 2 FiberWire. The knot is then tied blindly in the cannula on the outside of the anterior capsule as the closure is visualized through the posterior portal.
Posterior Portal Closure
A crescent suture passer is advanced from the posterior portal through the posterior capsule just above the medial border of the capsular opening of the posterior portal (TECH FIG 3A).
A no. 0 PDS suture is then fed into the joint and retrieved with a penetrator through the lateral border of the capsular opening in the posterior portal (TECH FIG 3B).
The PDS suture is then withdrawn out the posterior cannula and exchanged for a no. 2 FiberWire. The knot is tied blindly in the cannula on the outside of the posterior capsule as the closure is visualized through the anterior portal (TECH FIG 3C).
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TECH FIG 2 • A. Drawing depicting the single or multipleated plication. B. Placement of anchor on the rim of the glenoid. C. Passage of suture through labrum using a suture passer. D. Passage of spectrum suture passer in the capsular tissue and placement of no. 1 PDS suture. E. Passage of PDS suture into joint through capsular tissue. F. Passage of FiberWire suture through capsulolabral tissue after multipleated passage. G. Completed tied knot after first anchor and capsular plication. H. Residual labral tear remaining after first anchor placed and capsule plicated. I. Placement of second anchor as necessary for the capsulolabral repair and plication. J. Completed plication with multiple anchors.
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TECH FIG 3 • A. Placement of crescent suture passer through posterior capsular and passage of PDS suture into the joint. B. Passage of suture grasper through posterior capsule for closure of posterior portal.
C. Completed closure of the posterior portal following capsular plication.
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Surgical
indications
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Persistent pain and functional disability despite appropriate aggressive
rehabilitation program
Contraindications ▪ Voluntary dislocators or failure to comply with postoperative rehabilitation
program
Plication
technique
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Single or multiple passage of same suture through capsule allows varied
amount of volume reduction to address capsular laxity.
Posterior portal
closure
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Posterior portal closure allows added capsular volume reduction and
prevents potential posterior capsule tear from portal location.
Axillary nerve
injury
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Aggressive passage of spectrum in the inferior capsule places axillary nerve
at risk. Shallow capsular penetration prevent injury to axillary nerve.
Recurrent
instability
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Inadequate capsular volume reduction may allow recurrent instability.
Multipleated technique allows greater capsular volume reduction and restoration of normal tension.
PEARLS AND PITFALLS
POSTOPERATIVE CARE
Follow-up
The patient is discharged to home on the day of surgery. The sutures are removed 7 to 10 days later.
Rehabilitation
The arm is immobilized in an UltraSling (DonJoy, Carlsbad, CA) for 6 weeks.
Thirty degrees abduction in neutral rotation
The sling is removed for bathing and for gentle pendulum, and elbow, wrist, and hand range-of-motion exercises.
Isometric exercises are started at week 3.
Passive range of motion is begun within the first 2 weeks. Discontinue sling at week 4.
Active and active-assisted range of motion start at week 4. Sport-specific exercises at 4 months
Begin overhead sports at 5 to 6 months.
Return to contact sports at 6 to 8 months.
OUTCOMES
Summary of clinical studies (Table 1)
There have been several studies investigating the effect of surgical intervention on capsular volume.
Comparisons have been made between open capsular shifts using numerous techniques, arthroscopic thermal plication, and arthroscopic suture capsular plications by testing capsular volume in cadaveric specimens before and after procedures.
Table 2 summarizes the results and type of shift performed in these studies.
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COMPLICATIONS Loss of motion Recurrence of instability Neurovascular injury Failure to address missed causes of instability Large Hill-Sachs lesions that cause instability and are not addressed at surgery may lead to recurrence.27
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Table 1 Summary of Clinical Studies of Arthroscopic Treatment of Multidirectional Shoulder Instability
Author (Date) Procedure Performed Follow-up Outcome
Duncan & Scope inferior capsular 12-36 mo 100% satisfactory Savoie shift (1993)5
Pagnani et al Scope stabilization using Avg = 55 mo 74% good/excellent |
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(1996)21 transglenoid sutures (range: 48-120
mo)
McIntyre et al (1997)17
Scope capsular shift Avg = 34 mo 95% good/excellent
Treacy et al (1999)29
Scope capsular shift Avg = 60 mo 88% satisfactory
Gartsman et al. (2000)11
Scope labral repair + laser capsulorrhaphy
Avg = 33 mo (range: 26-63 mo)
92% good/excellent
Tauro (2000)28
Scope inferior capsular split/advancement
Range: 24-60 mo 88% satisfactory
Fitzgerald et al (2002)8
Scope thermal capsulorrhaphy
Avg = 36 mo (range: 24-40 mo)
76% satisfactory
Favorito et al (2002)7
Scope laser-assisted capsular shift
Avg = 28 mo 81.5% success
Frostick et al (2003)10
Scope laser capsular shrinkage
Avg = 26 mo (range: 24-33 mo) 83%
satisfactory
D'Alessandro et al (2004)4
Scope thermal capsulorrhaphy
Avg = 38 mo (range: 24-60 mo)
63% satisfactory
Alpert et al (2008)1
Arthroscopic panlabral repair
Avg = 56 mo (range: 29-72 mo)
85% satisfactory
Baker III et al (2009)2
Arthroscopic stabilization Avg = 34 mo 91% satisfactory (range of
motion) 86% return to sports
Ma et al (2012)16
Arthroscopic pancapsular plication
Avg = 36 mo (range: 24-61 mo)
100% satisfactory (stability) 5 of 23 return to sports
Jacobson et al (2012)12
Systematic review: arthroscopic vs. open
7 studies 219 shoulders
No clear advantage of open vs. arthroscopic
Avg, average.
Table 2 Summary of Results of In Vitro Capsular Volume Studies
Author (Date)
Type of Capsular Shift Amount of Volume Reduction
Miller et al (2003)18
Three open (medial, lateral, vertical)
Medial = 37% Lateral = 50% Vertical = 40%
Karas et al (2004)13
Three arthroscopic (thermal, suture plication, combined)
Scope thermal = 33% Scope plication = 19% Scope combined = 41%
Victoroff et al (2004)30
Arthroscopic thermal Scope thermal = 37%
Luke et al (2004)15
Open inferior vs. arthroscopic thermal
Open inferior = 50% Scope thermal = 30%
Cohen et al (2005)3
Open lateral vs. arthroscopic plication
Open lateral = 50% Scope plication = 23%
Flanigan et al (2006)9
5- and 10-mm arthroscopic capsular shift
5-mm shift = 16% 10-mm shift = 34%
Sekiya et al (2007)25
Open inferior vs. arthroscopic multipleated plication
Open inferior = 45% Scope multipleated = 58%
Wiater & Vibert (2007)31
Open humeral-based shift followed by release and shift
Initial shift = 33% First release and shift = 42% Second release and shift = 66%
Ponce et al (2011)22
Multiple 1-cm arthroscopic plication sutures
For every 1-cm plication suture = 10% reduction in capsular volume (5 stitches = 50% volume reduction)
Lubiatowski et al (2012)14
Arthroscopic shift (cadaver and clinical)
Cadaver = 38% Clinical = 59%
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