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Anterior Shoulder Instability
Arthroscopic Suture Capsulorraphy
Glenohumeral instability results from a combination of the following abnormalities: capsuloligamentous laxity, labral detachment, loss of glenoid concavity, humeral head or glenoid bone deficiency, diminished glenohumeral joint compression, loss of articular surface adhesion/cohesion forces, or loss of negative intraarticular pressure.
When glenohumeral instability results from capsuloligamentous laxity in the absence of capsulolabral detachment, capsular reconstruction procedures are indicated to reestablish the proper tension and length off these “ligaments.” Established open surgical procedures accomplish this by shortening the capsule or by shifting its bony attachments. Arthroscopic suture capsulorraphy combines both of these techniques to reduce intracapsular volume and restore proper tension to the glenohumeral capsule (and ligaments).
Indications
1. Symptomatic glenohumeral instability resulting from capsuloligamentous laxity without labral detachment
2. Failure of an appropriate rehabilitation program
Contraindications
1. Patients with inadequate capsular tissue for suture capsulorraphy: (a) thin, flimsy tissue, (b) absent capsule, or (c) severe hyperelastic soft tissue disorders
2. Patients with noncapsular etiologies for glenohumeral instability: (a) bony deficiency (glenoid or humeral), (b) labral detachment (Bankart or Perthes lesion), or (c) instability due to rotator cuff tear
3. Patients who have a pattern of voluntary instability, and clinical circumstances that suggest that the instability results in secondary gain
4. Those patients who are unable to comply with and complete an appropriate postoperative rehabilitation program
Mechanism of Injury
Capsuloligamentous laxity may result from repetitive, stretching, micro-trauma to the capsule or recurrent atraumatic subluxations and low energy dislocations.
Physical Examination
Positive findings include:
1. Increased glenohumeral translation with load and shift testing
2. Positive apprehension and apprehension suppression tests
3. Increased external rotation (in abduction) for patients with anterior instability, and increased internal rotation for patients with posterior instability
4. Capsular tenderness in the area of laxity after an acute instability episode
Negative findings include:
1. Absence of glenolabral grinding with subluxation/relocation during load-and-shift maneuvers
Diagnostic Tests
1. Radiographic views to exclude other pathology:
a. A standard three-view shoulder series consisting of (a) true anteroposterior (AP) of the glenohumeral joint, (b) an axillary lateral, (c) and a coracoacromial outlet (or arch) view.
b. Additional views are performed as necessary: internal rotation/external rotation AP views (for calcific deposits or Hill-Sach’s lesions), Stryker-notch view (for Hill-Sach’s lesions), and the West Point axillary lateral for bony Bankart lesions).
2. Magnetic resonance imaging or computed tomography arthrogram may be performed to exclude labral or rotator cuff pathology, or to evaluate for bony deficiency. (These studies are infrequently necessary for these patients.)
3. Examination under anesthesia (EUA) will show significantly increased glenohumeral translation in the direction of clinical instability.
Special Considerations
Hyperelastic patients and patients with connective tissue disorders (such as Ehler-Danlos syndrome) are at an increased risk for recurrence of instability. Young patients (under age 20) also seem to have an increased risk of recurrence.
Preoperative Planning and Timing of Surgery
The direction and degree of instability is determined from the history of injury and physical exam. An EUA is very important to assess the location and amount of abnormal capsular laxity (patholaxity) present. This information will guide you in deciding upon the location and extent of capsular tightening required to correct the instability.
This is an elective procedure. In most cases, surgery is not performed until an appropriate rehabilitation program has been implemented and has been unsuccessful. The decision to proceed with surgery is based upon the degree of instability and the severity of functional impairment. If surgery is to follow a recent traumatic dislocation, a preoperative attempt to regain normal range of motion is desirable to avoid postoperative stiffness.
Special Instruments
1. Arthroscopic video system
2. Shoulder traction setup (if using the lateral decubitus position)
3. Arthroscopic fluid pump (improves visibility and joint distention)
4. Clear plastic “working cannula” of appropriate diameter to allow passage of the suture passing devices
5. Arthroscopic probe
6. Synovial rasp or “whisker” shaver blade (to abrade the capsular surface)
7. Suture passing device(s):
a. 90-degree curved suture hook (preferred)
b. Other shapes of suture hook (preferred)
c. Caspari-type suture punches
8. Suture Shuttle Relay (Linvatec, Largo, FL) to be used with the suture-passing device if you plan to use braided suture for the repair
9. Suture retriever or grasper
10. Arthroscopic knot pusher
11. Suture-cutting basket forceps or scissors
12. Mosquito clamp
Anesthetic Options
1. General (author’s preference)
2. Regional
Patient and Equipment Position
1. Lateral decubitus (preferred)
2. Beach chair
Surgical Approach
1. Once adequate anesthesia is administrated, perform a thorough EUA and compare to the uninvolved shoulder as needed.
2. Prep and drape the patient giving clear access to the anterior, superior, and posterior aspects of the shoulder. Any patient positioning devices used (beanbags, bolsters, bracing pads) must be placed so as not to obstruct insertion and use of the arthroscope and instruments.
3. Position the arm in approximately 55 to 65 degrees of abduction.
4. Establish a posterior glenohumeral portal slightly lateral to the glenohumeral joint line and 1 to 2 cm below the posterior border of the acromion.
5. Establish an anterior portal in the rotator interval just behind the long head biceps tendon, at the anterior-inferior border of the supraspinatus.
6. Perform a complete diagnostic arthroscopic examination, viewing the joint from both the anterior and posterior portals.
7. Place a “working cannula” just superior to the tendinous margin of the subscapularis and lateral to the plane of the glenoid.
8. Prepare the capsule for suturing by excoriating the synovial layer off its surface. This is performed using the arthroscopic rasp or by cautious use of a “whisker”-type shaver blade, taking care to preserve capsular tissue. Capsular preparation should result in a mildly bleeding surface but should not result in removal of capsular tissue. Similar preparation of the labral surface is performed.
9. Use a 90-degree suture hook to take a 5 mm “bite of capsule” in the inferior pouch. This bite of capsule should be centered at a point 5 to 15 mm lateral to the capsulolabral junction (depending upon the amount of capsular tightening required) (Fig. 25–1).
10. Use the 90-degree suture hook to pull the capsule medial toward the labral margin and then shift it superiorly to properly tension the inferior capsular pouch. While the “bite of capsule” remains held on the suture hook, take a second bite through the labrum. Pass the suture (or the suture shuttle relay) through the capsule and labrum and into the joint (Fig. 25–2).
11. Withdraw the suture hook from the joint, then retrieve the suture from the joint. If a suture shuttle relay is used, withdraw it through another portal, load it with the braided suture, and pull it back through the capsule. Retrieve the suture out the working portal.
12. Tie an arthroscopic knot in the suture to firmly attach the capsule to the labrum (Fig. 25–3).
13. Probe the inferior pouch. If you are not satisfied with the amount of capsular tightening, remove the suture and repeat steps 8 to 12 (adjusting the amount of capsular advancement) until satisfied.
14. Repeat steps 8 to 12 as needed to place sutures as follows:
a. Place a second suture in the inferior glenohumeral ligament (IGHL) and advance it to, or superior to, the equator (midpoint) of the glenoid labrum to achieve proper tension (Fig. 25–4).
b. Place a third suture in the midportion of the capsule (for an anterior capsulorraphy, superior to the IGHL and inferior to the middle glenohumeral ligament (MGHL) and advance it up to the “superior quadrant of the glenoid.”
c. Place a fourth suture in the MGHL (for an anterior capsulorraphy or in the upper midportion of the posterior capsule for a posterior capsulorraphy) and advance it to the superior labrum (Fig. 25–5).
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