Management of Complications of Surgery for Anterior Shoulder Instability

Effect of nonablative laser energy on the joint capsule: an in vivo rabbit study using a holmium:YAG laser

BACKGROUND AND OBJECTIVE

The nonablative application of holmium:yttrium-aluminum-garnet (Ho:YAG) laser energy to the joint capsule of patients with glenohumeral instability has been found to shrink capsular tissue and to help stabilize the joint. The purpose of this study was to evaluate the effect of nonablative laser energy on the short-term histological properties of joint capsular tissue in an in vivo rabbit model.

STUDY DESIGN/MATERIALS AND METHODS

Eighteen mature New Zealand white rabbits were used in this study. One randomly selected stifle was treated with laser energy, and the contralateral stifle was sham-operated. Animals were euthanized immediately after surgery (day 0), at 7 days postsurgery and 30 days postsurgery. Specimens were processed for histology and transmission electron microscopy.

RESULTS

Laser-treated samples at day 0 showed diffuse hyalinization of collagen with nuclear karyorrhexis of fibroblasts. Laser-treated tissue at 7 days postsurgery revealed fibroblast proliferation around and into acellular hyalinized regions of collagen. At 30 days postlaser treatment, areas of fused collagen were greatly reduced as large reactive fibroblasts migrated and secreted matrix.

CONCLUSION

This study illustrates the short-term in vivo tissue response to nonablative laser treatment, where acellular hyalinized regions of collagen are infiltrated by fibroblasts that have used the treated collagen as the framework for migration and secretion of new collagen matrix in order for tissue repair to proceed.

Shoulder dislocations in the young patient

Shoulder dislocations are often seen in young patients, particularly those patients involved in collision sports. A conservative approach to treating these injuries includes protection from early re-injury, rehabilitation, and gradual return to athletics and use. It is important to recognize associated injuries such as fractures and nerve injuries. Surgical management is considered early for the small subgroup with the highest risk of recurrence: young athletes suffering a first traumatic dislocation returning to competitive athletics. Late operative repair is reserved for those who fail extensive nonoperative management.

Selective capsular shift technique for anterior and anterior-inferior glenohumeral instability

Anterior and anterior-inferior glenohumeral instability is often successfully treated with nonoperative measures, especially in atraumatic instability. In the case of traumatic instability, especially when the labrum is detached from the anteroinferior glenoid rim, surgery is often necessary to stabilize the shoulder and restore function. An anatomic repair that addresses any capsular or labral defect is essential for a successful outcome, and the selective capsular shift technique offers the flexibility necessary to correct these deformities. Several equally important steps must be followed when treating anterior and anterior-inferior glenohumeral instability. These include the correct diagnosis and indications for surgery; a technically successful surgical procedure; and diligent, physician-directed, closely monitored rehabilitation.

The effect of thermal heating on the length and histologic properties of the glenohumeral joint capsule

The purpose of this study was to evaluate the effect of temperature on shrinkage and the histologic properties of glenohumeral joint capsular tissue. Six fresh-frozen cadaveric shoulders were used for this study. Seven joint capsule specimens were taken from different regions from each glenohumeral joint and assigned to one of seven treatment groups (37 degrees, 55 degrees, 60 degrees, 65 degrees, 70 degrees, 75 degrees, 80 degrees C) using a randomized block design. Specimens were placed in a tissue bath heated to one of the designated temperatures for 10 minutes. Specimens treated with temperatures at or above 65 degrees C experienced significant shrinkage compared with those treated with a 37 degrees C bath. The posttreatment lengths in the 70 degrees, 75 degrees, and 80 degrees C groups were significantly less than the pretreatment lengths. Histologic analysis revealed significant thermal alteration characterized by hyalinization of collagen in the 65 degrees, 70 degrees, 75 degrees, and 80 degrees C groups. This study demonstrated that temperatures at or above 65 degrees C caused significant shrinkage of glenohumeral joint capsular tissue. These results are consistent with histologic findings, which revealed significant thermal changes of collagen in the 65 degrees, 70 degrees, 75 degrees, and 80 degrees C groups. To verify the validity of laser application for shrinkage of joint capsule, studies designed to compare these findings with the effects of laser energy must be performed.

The effect of nonablative laser energy on joint capsular properties. An in vitro histologic and biochemical study using a rabbit model

The purpose of this study was to evaluate the effect of laser energy at nonablative levels on joint capsular histologic and biochemical properties in an in vitro rabbit model. The medial and lateral portions of the femoropatellar joint capsule from both stifles of 12 mature New Zealand White rabbits were used. Specimens were divided into three treatment groups (5 watts, 10 watts, and 15 watt) and one control group using a randomized block design. Specimens were placed in a 37 degrees bath of lactated Ringer's solution and laser energy was applied using a holmium:yttrium-aluminum-garnet laser in four transverse passes across the tissue at a velocity of 2 mm/sec with the handpiece set 1.5 mm from the synovial surface. Histologic analysis revealed thermal alteration of collagen (fusion) and fibroblasts (pyknosis) at all energy densities, with higher laser energy causing significantly greater morphologic changes over a larger area (P < 0.05). Application of laser energy did not significantly alter the biochemical parameters evaluated, including type I collagen content and nonreducible crosslinks (P > 0.05). This study demonstrated that nonablative laser energy caused significant thermal damage to the joint capsular tissue in an energy-dependent fashion, but type I collagen content and nonreducible crosslinks (P > 0.05). This study demonstrated that nonablative laser energy caused significant thermal damage to the joint capsular tissue in an energy-dependent fashion, but type I Collagen content and nonreducible corsslinks were not significantly altered.

The effect of nonablative laser energy on the ultrastructure of joint capsular collagen

This study was designed to evaluate the effect of laser energy at nonablative levels on the ultrastructure of joint capsular collagen. The femoropatellar joint capsules of six mature New Zealand white rabbits were harvested immediately after death. Specimens were divided into three treatment groups (5, 10, and 15 watts) and one control group. Laser energy was applied using a holmium: YAG laser. Transmission electron microscopy showed significant ultrastructural alterations in collagenous architecture for all laser treatment groups, with increased fibril cross-sectional diameter for each of the treated groups. The fibrils began to lose their distinct edges and their periodical cross-striations at subsequently higher energy densities. A morphometric analysis showed that each subsequently higher laser energy caused a significant increase in collagen fibril diameter. Ultrastructural alteration of collagen fibril architecture caused by the thermal effect of laser energy is probably the dominant mechanism of laser-induced tissue shrinkage.