Reconstruction of the antero-superior shoulder capsule with the subscapularis tendon: A case report

Sources, Quality, and Reported Outcomes of Superior Capsular Reconstruction: a Systematic Review

PURPOSE

Superior capsular reconstruction (SCR) has gained attention as a potential treatment option for those with massive irreparable rotator cuff tears without significant arthritis. The aim of this systematic review is to review and evaluate the current sources and quality of SCR literature as well as reported outcomes.

METHODS

Three databases (PubMed, Ovid [MEDLINE], and EMBASE) were searched independently and in duplicate to systematically screen the literature. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist guided the reporting and data abstraction. The results are presented in a narrative summary fashion using descriptive statistics.

RESULTS

Overall, 58 studies were identified, including 304 different patients. There was a rapid increase in the number of publications observed over the past 3 years, with the most dramatic single-year increase noted from 2017 to 2018 (175% increase). There are no level 1 studies, and 95% of the included studies were level 4 and 5 evidence. Comparing pre-operative to post-operative pooled-weighted mean outcome scores, the American Shoulder and Elbow Surgeons score improved from 44.2 to 84.8, the Visual Analogue Scale from 5.0 to 1.5, and acromiohumeral distance from 6.5 to 8.4 mm, respectively. Range of motion in forward elevation also improved from 111° to 152°. Among studies reporting, the complication rate was 13.4% with a revision surgery rate of 4.3%.

CONCLUSION

Over the past 3 years there has been considerable growth in the number of publications of publications related to SCR. Despite a lack of high-quality clinical evidence, preliminary available evidence does suggest promising results both functionally and radiographically. There is a need for future higher-quality research such as large randomized controlled trials to improve our current understanding of the benefits of SCR.

Dynamic Anterior Stabilization Using the Long Head of the Biceps for Anteroinferior Glenohumeral Instability

Anteroinferior glenohumeral instability can be treated by variants of the Bankart repair, remplissage, and the Latarjet procedure, although all options remain associated with complications, including recurrence, stiffness, persistent pain, apprehension, and dislocation arthropathy. The authors therefore thought of a concept of dynamic anterior stabilization to treat anteroinferior glenohumeral instability by transferring the long head of the biceps within a subscapularis split to the anterior glenoid margin, thereby creating a "sling effect" by using a conservative technique. A standard Bankart repair is then to re-establish the labral damper effect. The main benefit of the dynamic anterior stabilization procedure is that it grants the "sling effect," but is easier and safer than arthroscopic Latarjet. It does not require screws nor traction of the coracoid process, and should therefore reduce the risks of neurologic damage. Furthermore, the procedure can be performed with only 3 small incisions, because it does not require coracoid transfer, which eliminates risks of nerve dissection, graft overhang, and cortical resorption, hence reducing the probability for dislocation arthroplasty. Lastly, the pectoralis minor remains intact, which would avoid scapular dyskinesis.

Bankart augmentation for capsulolabral deficiency using a split subscapularis tendon flap

Traumatic anterior shoulder instability is a frequent problem and often requires surgical management. In the absence of significant bone deficiency, arthroscopic capsulolabral repair is associated with low recurrence rates and good functional outcome. However, capsulolabral deficiency, particularly after multiple previous attempts at repair, may preclude traditional arthroscopic Bankart techniques. Previous reports have described the use of autograft or allograft augmentation or coracoid transfer in the treatment of this difficult problem. The purpose of this report is to describe a novel technique of arthroscopic Bankart augmentation of capsulolabral deficiency using a split subscapularis tendon flap to reinforce a damaged capsule. In the absence of bone deficiency, this technique can restore anterior shoulder restraint without excessively constraining the glenohumeral joint.

The anatomy and histology of the rotator interval capsule of the shoulder

Forty-seven rotator interval regions from fetuses and 10 fresh-frozen rotator interval regions from adult cadavers were evaluated by gross dissection and light microscopy. Specimens from adults also were evaluated with ultrasound and magnetic resonance imaging. An analysis of 37 fetal specimens (> 14 weeks gestation) revealed two rotator interval types: Type I (9 of 37) was defined by a contiguous bridge of capsule consisting of poorly organized collagen fibers. A Type II rotator interval (28 of 37) had a complete defect covered by only a thin layer of synovium. Similar to the Type II rotator interval in the fetus, a rotator interval defect was present in six of eight specimens from adults. Histologically, the capsular tissue within the rotator interval consisted of poorly organized collagen fibers in specimens from the fetus and adult. Maximal opening of the rotator interval was seen by ultrasound with internal rotation and downward traction of the hyperextended arm in the coronal, oblique, and sagittal planes. Magnetic resonance imaging of the rotator interval region permitted anatomic evaluation. The complete absence of tissue in 28 of 37 fetuses suggests that the rotator interval defect is congenital. The authors recommend that surgeons carefully evaluate the integrity of the tissue within the rotator interval. When rotator interval closure is desired such as in patients with a persistent sulcus sign after arthroscopic stabilization, suturing the edges of more substantial tissue immediately adjacent to the boundaries of the rotator interval region would seem prudent.

Glenohumeral kinematics and capsulo-ligamentous strain resulting from laxity exams

OBJECTIVE

Identification and quantification of strain in shoulder capsular-ligamentous structures during clinical exams and validation of this testing on cadavers.

METHODS

Mercury strain gauges were sutured in seven locations on shoulders from cadavers. An electromagnetic tracker quantified humeral head translations during laxity exams. Strain and humeral position were acquired during performance of Sulcus, Feagin, Apprehension, Load and Shift, Drawer, and Hawkins tests.

RESULTS

Anterior humeral head translation in neutral position was primarily constrained by the coracohumeral ligament. With the arm abducted, anterior middle and inferior ligaments also became active. External rotation and abduction activated inferior and middle capsules. Posterior capsule constrained motion for posterior tests in neutral and abduction. Superior and inferior capsular ligaments were active during inferior tests in neutral position. With abduction, inferior ligaments provided primary translation constraint.

CONCLUSION

Study of kinematics and strain evaluation on cadavers can yield useful information on mechanisms of glenohumeral instability. Relevance This study clarifies the contribution of specific structures of the shoulder to strain in the joint capsule. It also identifies which structures are challenged by provocative laxity exams commonly used by orthopaedic physicians.

Rotator interval lesions and their relation to coracoid impingement syndrome

In the last 10 years we have found impingement of the coracoid process on the rotator interval in 12 patients (14 shoulders). Seven of these patients were women and 5 were men; the average patient age was 48.5 years. One patient had a calcified coracohumeral ligament, another patient had an anterior tear of a repaired deltoid flap, and a third had an aberrant pectoralis minor tendon inserted into the rotator interval. Eleven patients had a weak rotator interval, and in 4 cases the rotator interval had a small tear. We closed the rotator interval in all 12 patients. We also performed a coracoidoplasty in 5 of the patients. The condition of all shoulders improved clinically after operation; the average follow-up was 4.2 years. Three patients (4 shoulders) still had moderate pain, and 7 patients (9 shoulders) lacked strength. Internal rotation was the only shoulder movement that remained limited. Although impingement seemed obvious during surgery, experimental studies have reported contradictory findings.