| Year : 2007 | Volume : 1 | Issue : 1 | Page : 2-6 |    |
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We have developed an arthroscopic technique to reinforce the torn inferior glenohumeral ligament and the elongated strained capsule, with no need for hardware implants: the arthroscopic capsuloplasty. We have assessed early results of arthroscopic capsuloplasty on seven active athletes, observed for a painful unstable shoulder. All cases presented with anterior inferior capsular distension and a strained or ruptured IGHL; these are indications for this technique, independent of the presence of a Bankart lesion. Cases where a Bankart lesion was also repaired were not considered in these preliminary results. As with an open standard Neer capsular shift, an arthroscopic capsular re-tightening is performed, by means of a shift of the anteroinferior capsule incised one centimeter from the glenoid rim. Results with an average follow-up of 12 months were appraised following the Walch-Duplay score. The global result was bad for one patient with a retractile capsulitis after 6 months and good for another at 13 months after surgery. The remaining five patients had excellent global results and have resumed sports at the same level as before. The authors consider this technique to be an alternative to thermal capsular shifts and open procedures, although the series is limited and follow-up short, yet with quite encouraging results. Level of evidence : Case Series (level IV).
Keywords: Capsular shift, capsuloplasty, shoulder arthroscopy
| How to cite this article: Hardy P, Gomes N, Bauer T, Poulain S. Arthroscopic glenohumeral capsular shift: Technical note and preliminary results. Int J Shoulder Surg 2007;1:2-6 |
Widespread practice of arthroscopy on painful and unstable shoulders has shown that part of this population (about a sixth) does not present with any labral lesion, but only elongation or rupture of the inferior glenohumeral ligament (I.G.H.L.).[1],[2] This observation confirms the dominant role of the I.G.H.L as the anterior inferior stabilizer of the glenohumeral joint and therefore the relevance of its fixation.[3] When a Bankart lesion is associated with it, reinsertion of the capsulo-labral complex to the anterior rim of the glenoid should lead to a simultaneous tightening of the I.G.H.L. Treatment of this capsular and I.G.H.L plastic deformation is therefore a key factor in the therapeutic success of shoulder instabilities[4],[5],[6] and failure to address this in the arthroscopic procedure can explain the superior results with a classic open Neer’s operation compared to an arthroscopic procedure, except if associated with thermal capsular shrinkage.[7],[8],[9] Indeed, thermal shrinkage is one of the few techniques allowing treatment of the loose anterior capsule by arthroscopy. That procedure has been much debated because it has shown its limits (cost of the Holmium: Yag Laser), its risks (depth of thermic lesions are difficult to control)[10] and some failures.[11] More recently, other authors have described techniques with the same purpose, but still with no long term results: reinsertion of capsule to the anterior glenoid rim with anchors[12] and an arthroscopic capsular shift by means of a capsular reattachment to a bone trough on the humeral head.[13] Tauro[14] has shown good or excellent results on 88% of his cases after an arthroscopic capsular split, using either transglenoid drill holes or anchors for sutures. We have developed an arthroscopic technique that avoids thermal shrinkage as well as usage of hardware such as anchors, tacks or staples, working only on the capsule and glenohumeral ligaments, sparing all osseous structures. In the absence of a Bankart lesion, we believe that tightening of the I.G.H.L can be achieved thanks to this new arthroscopic technique, the first results of which on a series of seven patients are described here. Our experience has also shown it can be accompanied by an arthroscopic Bankart repair if needed.
We have reviewed seven patients who had been operated on for a painful and unstable shoulder, with an average follow-up of 12 months. Three were males and the average age was 27 years old (19-40). Two were leisure sportsmen and the remaining five practiced sports on a professional basis; of these three were national-ranked and two were regional-ranked athletes. The dominant shoulder was affected in four cases and all had normal range of motion. Only one patient referred to a true dislocation (8 years prior to observation) followed by subluxations. Four patients had episodes of subluxations (1st episode 3 years prior to surgery on average) and two patients presented with shoulder pain with arm elevation, without any definite history of instability.Examination for instability was classical in five patients with a positive sulcus sign and positive anterior and inferior apprehension tests. One patient had a hyperlax shoulder, defined as external rotation over 85º at 0º of abduction and positive anteroposterior drawer tests and another had no obvious clinical instability on outpatient observation, with a positive anterior drawer test under general anesthesia.
All patients were selected for this procedure intra-operatively, which is a distinctive characteristic of arthroscopic capsuloplasty. Capsular laxity or injury was assessed both by computerized arthrotomography, demonstrating a large baggy capsular pouch that created a capacious joint cavity and by direct observation on arthroscopy. The latter determined whether the glenohumeral ligaments were well-formed band-like thick structures or if there was thin, patulous tissue with poorly defined glenohumeral ligaments. This assessment method has been employed previously and has been shown to be valid and reproducible both clinically and experimentally.[4],[15] Evidence of an anterior-inferior distension of the capsule with a torn or absent I.G.H.L. but no labral disinsertion would modify the indication of a Bankart operation to a capsuloplasty. Combined capsular laxity and Bankart lesion were subject to labral reinsertion along with the capsular shift we developed, although these were not considered in this study. Exclusion criteriae were failure of previous surgery and voluntary dislocations.
Surgical technique
Basic setting
The patient is positioned either in beach-chair position or lateral decubitus with double traction to the upper limb. In both cases an arthropump set to a pressure of 50 mmHg is used and the portals are classical: standard posterior viewing portal and an anterior portal (in/out Wissinger technique) for the instruments. Instrumentation would be the same as for a Bankart operation, facilitating intraoperative change of indication from a Bankart repair to capsuloplasty. In addition, there is no need for anchoring materials to the glenoid.
Repair technique
Capsular incision : Capsuloplasty implies resuturing an incised capsule in a way that this leads to a South/North and East/West retightening, as described by Neer in an open procedure.[16] The retightening occurs as the capsule is pulled forward to tighten the posterior part of the capsule until posterior subluxation no longer occurs and upward until the inferior capsular pouch is eliminated. An incision is made from the lower to upper part of the capsule (from 6 to 2 o’clock on a right shoulder), 1 cm lateral to its labral insertion, using a thermal cutting probe. The incision should thoroughly cut the whole capsule until the deep fibers of sub-scapularis are exposed; care is taken to protect the axillary nerve from any lesions.
Iatrogenic capsular detachment. A large capsulomuscular dissection is then carried out on the humeral side of the incised capsule using either a standard arthroscopic hook or a small sharp elevator, in order to facilitate a substantial capsular shift [Figure – 1],[Figure – 2].
Suture placement and capsular shift: A first stitch, the most inferior, is made by grasping the lateral rim of the incised capsule, as low as possible, with the arthroscopic suture passer (Linvatec Suture Hook®) loaded with an absorbable monofilament (Flexocrin® no. 1) suture [Figure – 3]. With an effect of superior and medial shift, the hook of the suture passer is then passed through the glenoid labrum as high as possible, creating an actual capsular plication [Figure – 4]. This first stitch would essentially close the inferior distension [Figure – 5]. Other stitches (generally 3 or 4) retighten the anterior capsule by reinserting the distal capsule at 3 and 2 o’clock in contact with the labrum, using the same technique as for the first stitch, thus creating a true capsular shift [Figure – 6]. Disappearance of the anterior distension and achieving contact between the humeral head and the capsule are indicators that capsular tightening is satisfactory.
Post-operative management
The shoulder is immobilized in a sling, avoiding abduction and external rotation for one month and anti-inflamatory drugs are prescribed. Physical rehabilitation follows immobilization: passive at first, then active-assisted and with progressive resistance. Contact sports with overhead arm movements are resumed by the 6th month.
Four patients had a healthy capsulo-labral complex. In one patient, the capsulo-labral complex had healed on the place of its desinsertion, while one had an ectopically healed complex (ALPSA). Another patient had a missing labrum antero-superiorly and was fragile and irregular antero- inferiorly. All patients had an intact rotator cuff, long head of biceps and cartilage. One had a worn anterior glenoid rim, another a minor Hill-Sachs lesion and two had SLAP lesions (types 1 and 2). Two patients had isolated I.G.H.L. distensions, two had I.G.H.L. ruptures with a cord-like M.G.H.L. and three patients had a large anterior-inferior distended pouch with strained I.G.H.L. and M.G.H.L. All patients were examined post-operatively after an average duration of 12 months (range 6 to 21 months) following the Walch-Duplay grid.[17] No neurological injury was registered in the immediate post-operative period or in the long term. One patient had a retractile capsulitis (6 months after surgery) with a stable, but painful shoulder, with reduced mobility and she has not resumed sports yet. Another patient had a similar episode classified as algodystrophy, which healed (13 months after surgery); the patient is now back to her handball team (national ranked), with a stable shoulder, yet slightly painful with forced movements and still with no symmetrical mobility (Walch-Duplay 80/100). The other five patients have had excellent results in terms of pain, mobility and stability and are back to sports at the same level as before (Walch-Duplay 100/100). Their external rotation, elbow by side (E.R. 1) and at 90 degrees abduction (E.R. 2), are symmetrical to those of the contralateral shoulder (less than 5 degrees difference). When asked if they would have this surgery done a second time, the former is the only one to have answered “no”.
Cole[4] performed an examination under anesthesia and a pre-therapy diagnostic arthroscopy on 63 unstable shoulders: the 39 patients (62%) with a Bankart lesion had them fixed arthroscopically and all the others with a loose capsule were treated with an open capsular shift. Results were similar in both groups after 54 months, which somehow illustrates the need for a good selection of patients for each technique. He therefore considered that these ‘non-Bankart lesions’ should be addressed with an open procedure, taking into account that open stabilization is, as many believe, the standard treatment.[4],[5] Our assessment of the patients was similar, except for the fact that capsular shift was done arthroscopically.
With an average follow-up of 12 months, we therefore have one bad, one good and five excellent results. We can hardly draw formal conclusions, as the number of patients is small and follow-up insufficient – according to the results of the 1993 Symposium of the French Society of Arthroscopy, recurrences after arthroscopic treatment of anterior instability arise in an average period of 15 months. Both cases of algodystrophy, from which one patient has almost completely recovered, are worrying and could be due to a large pre-operative articular volume. Therefore, as the capsule is re-tightened, one must pay attention to avoid overcorrection, probably underestimated in a shoulder put under tension by the use of an arthropump. Once more, expertise will surely be a key factor for success.
Several aspects of this procedure are encouraging. First of all, the surgeon’s satisfaction as he retightens the anterior inferior capsular distension as desired. A large iatrogenic detachment of the capsule enables formation of an anterior inferior fold; eliminating the pre-existing large pouch and creating an amount of capsular shift comparable to that of a classic open approach. Our technique, unike the classical Neer procedure, does not demand a T-like incision and therefore only one flap is securely sutured; however, by performing an inferior capsular split and advancement, may address posterior instability as well. Risk of neurological complications as well as deep lesions related to thermal shrinkage are minimized. The cost of this technique is quite appealing as it is limited to suturing materials with no need for implants. This fact also avoids the risk of loose hardware and permits combined reinsertion of the glenoid labrum in case of mixed lesions, such as a concomitant Bankart lesion. An essential aspect of this technique is preservation of the sub-scapularis muscle, unavoidable in open procedures. Numerous series have described short and long term complications of surgical techniques obliging its section, from rupture of the repaired subscapularis to fatty degeneration and recurrence of instability, especially serious in a young patient. In addition, in case of need for revision surgery, the option for an open approach remains a possibility. Of even more concern are reports of motion loss following open stabilization;[18] loss of external rotation being of major significance to high level athletes.
Besides the well-known advantages of an arthroscopic procedure, arthroscopic glenohumeral capsuloplasty seems to allow the on-demand retightening of the capsule and anterior glenohumeral ligaments, providing stability to painful and unstable shoulders with no Bankart lesion.
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Figures
[Figure – 1], [Figure – 2], [Figure – 3], [Figure – 4], [Figure – 5], [Figure – 6]
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