What Are the Effects of Capsular Plication on Translational Laxity of the Glenohumeral Joint: A Study in Cadaveric Shoulders

Occult, Incomplete, and Complete Posterior Labral Tears Without Glenohumeral Instability on Imaging Underestimate Labral Detachment

PURPOSE

To introduce a classification of posterior labral tear and describe clinical characteristics, magnetic resonance imaging (MRI)/magnetic resonance arthrography (MRA) findings, arthroscopic findings, and outcomes after arthroscopic repair for patients with posterior labral tears without glenohumeral instability.

METHODS

Sixty patients with posterior labral tear who underwent arthroscopic repair were analyzed retrospectively. Patients with shoulder instability were excluded. Tear patterns were classified into 3 types; occult (type 1), incomplete (type 2), and complete (type 3) based on MRI/MRA studies. A visual analog scale score for pain, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score for satisfaction, and return to sports were evaluated at a minimum follow-up of 2 years. Computed tomography arthrography was performed at a year follow-up for assess labral healing. The diagnosis was confirmed in arthroscopy, and arthroscopic labral repair without capsular plication was performed.

RESULTS

The mean patient age was 30.4 ± 6.9 years, and all patients were male. Forty-four patients (73.3%) were participating in sports. MRI/MRA studies identified 10 patients with type 1, 18 with type 2, and 32 with type 3 tears. Type 1 tear patients showed a significantly longer symptom duration than those with type 3 (32.5 ± 17.2 vs 18.2 ± 17.1 months; P = .015). In arthroscopic findings, 70% of type 1 tear was confirmed as incomplete or complete tears. The American Shoulder and Elbow Surgeons score improved from 79.6 ± 10.3 to 98.1 ± 3.7, and pain was relieved from 2.4 ± 0.7 to 0.2 ± 0.5 at the last follow-up visit with high labral healing rate (95%). Thirty-nine (88.6%) patients returned to sports at preinjury levels.

CONCLUSIONS

In active young men with shoulder pain during daily activities or sports despite programmed conservative treatment, posterior labral tears should be considered even when MRI/MRA findings are ambiguous. Arthroscopic posterior labral repair without capsular plication provided satisfactory clinical outcomes and a high labral healing rate.

LEVEL OF EVIDENCE

Level Ⅳ, case series.

The Longitude-Latitude-Loop Used for Complex Bankart Lesion Repair: An All-Arthroscopic Technique

The most frequent operation for anterior shoulder instability is the arthroscopic Bankart repair, which has a positive outcome and a low rate of complications. A variety of restoration procedures have been reported to reconstruct labral height and reproduce a dynamic concavity-compression reaction. The longitude-latitude loop is a knotless high-strength suture method that simultaneously tightens the joint capsule in the warp and weft direction and resists tearing. The suture method is safe and reproducible. This study aimed to present a longitude-latitude loop suture for joint capsule labral complex repair during Bankart arthroscopy surgery.

Management of Shoulder Instability in Patients with Underlying Hyperlaxity

PURPOSE OF REVIEW

Shoulder instability in patients with underlying joint hyperlaxity can be challenging to treat. Poorly defined terminology, heterogeneous treatments, and sparse reports on clinical outcomes impair the development of best practices in this patient population. This article provides a review of the current literature regarding optimal management of patients suffering from shoulder instability with concomitant hyperlaxity of the shoulder, from isolated shoulder joint hyperlaxity to congenital hypermobility spectrum disorders (HSD).

RECENT FINDINGS

Current research shows specialized physiotherapy protocols focused on strengthening of periscapular muscles and improvement of sensorimotor control are a promising non-surgical therapeutic avenue in certain patients, which can be augmented by device-based intervention in select cases. If surgical treatment is warranted, arthroscopic techniques such as pancapsular shift or plication continue to demonstrate favorable outcomes and are currently considered the benchmark for success. The long-term success of more recent innovations such as coracoid process transfers, conjoint tendon transfers, subscapularis tendon augmentation, and capsular reconstruction remains unproven. For patients affected by connective tissue disorders, treatment success is generally less predictable, and the entire array of non-operative and operative interventions needs to be considered to achieve the best patient-specific treatment results. In the treatment of shoulder instability and concomitant hyperlaxity, specialized physiotherapy protocols augmented by device-based interventions have emerged as powerful, non-operative treatment options for select patients. Successful surgical approaches have been demonstrated to comprehensively address capsular redundancy, labral lesions, and incompetence of additional passive stabilizers in a patient-specific fashion, respective of the underlying connective tissue constitution.

[Rebalancing theory of shoulder stability mechanism for the diseases related to the shoulder instability and dysfunction of motion]

Objective

To introduce a new theory of shoulder stability mechanism, rebalancing theory, and clinical application of this new theory for the shoulder instability and dysfunction of motion.

Methods

Through extensive review of the literature related to shoulder instability and dysfunction of the motion in recent years, combined with our clinical practice experience, the internal relation between passive stability mechanism and dynamic stability mechanism were summarized.

Results

Rebalancing theory of shoulder stability mechanism is addressed, namely, when the shoulder stability mechanism is destructive, the stability of the shoulder can be restored by the rebalance between dynamic stability mechanism and passive stability mechanism. When dynamic stability is out of balance, dynamic stability can be restored by rebalancing the different parts of dynamic stability mechanism or to strengthen the passive stability mechanism. When passive stability mechanism is out of balance, passive stability can be restored by rebalancing the soft tissue and bone of the shoulder.

Conclusion

Rebalancing theory of shoulder stability mechanism could make a understanding the occurrence, development, and prognosis of shoulder instability and dysfunction from a comprehensive and dynamic view and guide the treatment effectively.

Mapping of the Inferior Glenohumeral Ligament for Suture Pullout Strength: A Biomechanical Analysis

Background

Suture pullout during rehabilitation may result in loss of tension in the inferior glenohumeral ligament (IGHL) and contribute to recurrent instability after capsular plication, performed with or without labral repair. To date, the suture pullout strength in the IGHL is not well-documented. This may contribute to recurrent instability.

Purpose/Hypothesis

A cadaveric biomechanical study was designed to investigate the suture pullout strength of sutures in the IGHL. We hypothesized that there would be no significant variability of suture pullout strength between specimens and zones. Additionally, we sought to determine the impact of early mobilization on sutures in the IGHL at time zero. We hypothesized that capsular plication sutures would fail under low load.

Study Design

Descriptive laboratory study.

Methods

Seven fresh-frozen cadaveric shoulders were dissected to isolate the IGHL complex, which was then divided into 18 zones. Sutures in these zones were attached to a linear actuator, and the resistance to suture pullout was recorded. A suture pullout strength map of the IGHL was constructed. These loads were used to calculate the load applied at the hand that would initiate suture pullout in the IGHL.

Results

Mean suture pullout strength for all specimens was 61.6 ± 26.1 N. The maximum load found to cause suture pullout through tissue was found to be low, regardless of zone of the IGHL. Calculations suggest that an external rotation force applied to the hand of only 9.6 N may be sufficient to tear capsular sutures at time zero.

Conclusion

This study did not provide clear evidence of desirable locations for fixation in the IGHL. However, given the low magnitude of failure loads, the results suggest the timetable for initiation of range-of-motion exercises should be reconsidered to prevent suture pullout through the IGHL.

Clinical Relevance

From this biomechanical study, the magnitude of force required to cause suture pullout through the IGHL is met or surpassed by normal postoperative early range-of-motion protocols.

A comparative study on use of two versus three double-loaded suture anchors in arthroscopic Bankart repair

Objectives

This study aims to compare clinical results of repair using two versus three double-loaded suture anchors in arthroscopic Bankart repair.

Patients and methods

Between July 2012 and December 2017, a total of 40 patients (38 males, 2 females; mean age: 31.6±8.1; range: 17 to 47 years) who underwent Bankart arthroscopic surgery and were followed for minimum two years were retrospectively analyzed. Group 1 (n=17) underwent arthroscopic Bankart repair with two double-loaded suture anchors, while Group 2 (n=23) underwent repair with three double-loaded suture anchors. Clinical outcomes of the patients and recurrences were compared.

Results

At the final postoperative follow-up, a significant improvement was observed in the functional outcomes in all patients. No statistically significant difference was found (p>0.05) in the mean clinical scores of the Constant Shoulder Score between Group 1 (94.2±7.8) and Group 2 (95.4±4.1). There was no significant difference in the mean Rowe scores (Group 1: 95.6±4.6 vs. Group 2: 96.3±3.8, respectively) and external rotation loss (at neutral Group 1: 1.9o vs. Group 2: 2.2o, respectively). Three of our patients had recurrent dislocation during a major traumatic event (n=2 in Group 1 and n=1 in Group 2).

Conclusion

Our study results suggest that stability is not correlated with the use of either two versus three double-loaded suture anchors in arthroscopic Bankart repairs.

Influence of Glenoid Labral Bumper Height and Capsular Volume on Clinical Outcomes After Arthroscopic Bankart Repair as Assessed With Serial CT Arthrogram: Can Anterior-Inferior Volume Fraction Be a Prognostic Factor?

BACKGROUND

Arthroscopic labral repair combined with capsular plication decreases joint volume and restores glenoid labral bumper height; thus, the procedure helps decrease capsular redundancy. However, the decreased volume and restored glenoid labral bumper height could change over time, which could influence the outcome of the operation.

PURPOSE

To (1) measure glenoid labral bumper height and capsular volume quantitatively in serial computed tomography arthrography (CTA) and evaluate the relationship between bumper height and joint volume and (2) compare the difference in bumper height and joint volume between groups with and without apprehension after arthroscopic Bankart repair.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients who had undergone arthroscopic Bankart repair between January 2012 and June 2016, and were assessed by CTA 3 to 6 months and 12 to 18 months after the operation were included. An image reconstruction program (3-dimensional slicer) was used to calculate inferior, anterior-inferior, and posterior-inferior joint volumes; the ratio of the anterior-inferior volume to the inferior volume was defined as the anterior-inferior volume fraction (VF_AI). We also measured glenoid labral bumper height at the 5-, 4-, and 3-o'clock positions.

RESULTS

A total of 50 patients were enrolled as study participants (mean age, 25.2 ± 9.29 years). Of these, 10 patients had either redislocation or apprehension, and 40 patients had neither. A significant correlation was observed between 5-o'clock glenoid labral bumper height and VF_AI on early CTA (3-6 months) and late CTA (12-18 months) (early CTA: Pearson coefficient, -0.335, P = .040; late CTA: Pearson coefficient, -0.468, P = .003). VF_AI at the early CTA was 42.20 ± 10.15 in the group with apprehension and 33.49 ± 9.66 in the group without apprehension; a significant difference was observed. VF_AI at the late CTA was 45.84 ± 11.97 in the group with apprehension and 37.65 ± 9.70 in the group without apprehension and thus showed a significant difference between the 2 groups. However, the 3-, 4-, and 5-o'clock glenoid labral bumper heights on early and late CTAs did not show a statistically significant difference between the 2 groups.

CONCLUSION

Early postoperative VF_AI is related to postoperative apprehension and redislocation and might be reduced by increasing the 5-o'clock glenoid labral bumper height.

Can capsular plication compensate the lack of one suture anchor in an arthroscopic three suture anchor Bankart repair? A comparative study

Objective

The aim of this study was to compare the complication rates and clinical results of labral repair with two suture anchors and capsular plication, and labral repair with three suture anchor fixation in artroscopic Bankart surgery.

Methods

Sixty-nine patients (60 males, 9 females; mean age: 28.2 ± 7.8 years (range: 16–50)) who had undergone arthroscopic repair of a labral Bankart lesion were evaluated. Group A underwent an arthroscopic Bankart repair with three knotless suture anchors, while group B underwent a modified arthroscopic Bankart repair with two knotless suture anchors and an additional capsular plication procedure. The mean follow-up was 52.5 months. Constant Shoulder Score (CSS), Rowe Score (RS), modified UCLA Shoulder Score (mUSS) and range of motion (ROM) were used as outcome measures.

Results

In both groups, a significant improvement was detected in functional outcomes at postoperative last follow-up compared to the preoperative period. No statistically significant difference was found (p > 0.05) in clinical scores (CSS; Group A: 89.7, Group B: 80.2) (RS; Group A: 88.2, Group B: 80.2) (mUSS; Group A: 26.3, Group B: 25.7) external rotation loss (At neutral; Group A: 4.5°, Group B: 5.2°. At abduction; Group A: 4.3°, Group B: 5.7°) and recurrence rates (Group A: 13.3%, Group B: 20.8%). Although the difference was not statistically significant, the recurrence rate was higher in group B (20.8%), compared to group A (13.3%), despite the shorter average follow-up time of group B (p = 0.417).

Conclusions

Arthroscopic repair of labral Bankart lesions with both techniques showed good functional outcomes and stability at the latest follow-up. Higher recurrence rate despite the shorter average follow-up of group B suggests that two anchor usage might not be sufficient for Bankart repair in terms of better stability and less recurrence risk.

Level of evidence

Level III, Therapeutic Study.