The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 82, Issue 9

Articles | September 01, 2000

Capsulolabral Augmentation for the Management of Posteroinferior Instability of the Shoulder*

John Antoniou, M.D., PH.D., F.R.C.S.(C)†; David T. Duckworth, M.D.‡; Douglas T. HarrymanII, M.D.§

Investigation performed at the Department of Orthopaedics, University of Washington, Seattle, Washington
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.
†Orthopaedic Research Laboratory, Royal Victoria Hospital, Room L 4.69, 687 Pine Avenue West, Montreal, Quebec H3P 1H8, Canada. E-mail address: janton@orl.mcgill.ca.
‡116 Macguire Street, Parramatta, 2150 New South Wales, Australia.
§Deceased.

J Bone Joint Surg Am, 2000 Sep 01;82(9):1220-1220

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Abstract

Background: Posteroinferior instability of the shoulder has been associated with capsular laxity. The purposes of the present study were to describe the pathological morphology of the posteroinferior aspect of the glenolabral fossa in patients with primary posteroinferior instability and to prospectively examine the efficacy of managing this instability with use of an arthroscopic posteroinferior capsulolabral augmentation procedure.

Methods: Forty-one patients who had posteroinferior instability of the shoulder were managed with an arthroscopic shift of the posteroinferior aspect of the capsule to the adjacent labrum and were followed for a minimum of twelve months. Thirty-two patients had a primary procedure, and nine had a revision procedure. The mean duration of follow-up was twenty-eight months (range, twelve to sixty-nine months). All of the patients had presented with a symptomatic, positive finding on the jerk test and had participated in a minimum of six months of rehabilitation that had failed to relieve the symptoms. The patients were evaluated prospectively with a motion and stability examination and the Simple Shoulder Test. In addition, they completed the Short Form-36 Health Survey (SF-36) and a questionnaire on the outcome of treatment.

Results: Lesions affecting the posteroinferior aspect of the glenolabral concavity were seen in thirty-four patients (83 percent): five had labral detachment, seven had chondral or labral erosion, nine had capsular and synovial stripping, and thirteen had a labral split or tear. The mean score (and standard deviation) on the Simple Shoulder Test improved from 5.5 ± 3.4 points to 8.1 ± 3.3 points (p = 0.0023), and two of the eight SF-36 parameters improved significantly (p < 0.05). Conversely, nineteen patients who were receiving Workers' Compensation did not show any improvement in either of the two parameters. Thirty-five patients had improved stability of the shoulder, and the findings on all physical examinations had improved significantly (p < 0.0001). Twenty-eight patients had a perception of residual stiffness; this finding was in contrast to the mean score on the flexibility examination, which had not changed significantly at the time of the latest follow-up.

Conclusions: Posteroinferior instability of the shoulder is associated not only with capsular laxity but also with well defined lesions of the glenolabral concavity. Arthroscopic capsulolabral augmentation to reduce posterior capsular laxity and to restore the depth of the glenolabral concavity has been shown to be effective treatment of this condition after a mean duration of follow-up of twenty-eight months.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Surgical treatment of posteroinferior instability of the shoulder is associated with highly variable rates of success ranging from 50 to 70 percent^{11,15,17,23,27,29-31}. This type of instability is considered more difficult to diagnose and manage than traumatic anteroinferior instability. The specific pathological mechanism leading to posteroinferior instability is often attributed to excessive capsular laxity and a large capsular recess^{2,3,5,11,26,27,30,31,35}. Evaluation and treatment of this abnormality with use of arthroscopic techniques offers the opportunity to identify other associated lesions and to treat them when appropriate. The purposes of the present study were to describe the pathological morphology of the posteroinferior aspect of the glenolabral fossa in patients with primary posteroinferior instability and to prospectively examine the efficacy of managing this instability with use of arthroscopic posteroinferior capsulolabral augmentation.

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Fig. 1:: Arthroscopic image of the posteroinferior quadrant after stripped synovial tissue adjacent to the peripheral labrum has been lightly debrided with a motorized synovial resector blade. The suture-hook is passed through the capsule one centimeter peripheral to the labrum and through the junction of the inner annular labral fibers where they attach to the glenoid articular cartilage. A number-0 PDS (polydioxanone) suture is advanced and retrieved out of the operative cannula.

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Fig. 2:: Arthroscopic image showing the suture tied securely in order to pull the peripheral aspect of the capsule onto the articular glenoid labrum. If the inner annular fibers are intact, multiple number-0 PDS sutures are placed around the rim of the glenoid labrum to augment the depth of the glenolabral fossa. Alternatively, the rolled capsule and labrum are attached to the rim with suture anchors.

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Fig. 3-A:: Arthroscopic images of the rotator interval before closure (Fig. 3-A, arrowheads) and after closure (Fig. 3-B).

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Fig. 3-B:: Arthroscopic images of the rotator interval before closure (Fig. 3-A, arrowheads) and after closure (Fig. 3-B).

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Fig. 4-A:: Figs. 4-A through 4-D: Arthroscopic images of the four categories of glenoid lesions.
Fig. 4-A: Bankart-type labral detachment.

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Fig. 4-B:: Chondral or labral erosion.

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Fig. 4-C:: Synovial and capsular stripping (arrowheads).

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Fig. 4-D:: Tear or split of the labral flap.

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Fig. 5:: Graph showing the percent of patients who were able to perform each function of the Simple Shoulder Test.

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Fig. 6:: Graph showing the percent of the twenty-two patients who were not receiving Workers' Compensation who were able to perform each function of the Simple Shoulder Test.

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Fig. 7:: Graph showing the scores on the SF-36, expressed as a percent of matched population-based control values, before and after treatment. The Wilcoxon signed-rank test was used for the paired comparison.

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Fig. 8:: Graph showing the scores on the SF-36, expressed as a percent of matched population-based control values, before and after treatment, for the patients who were not receiving Workers' Compensation. The Wilcoxon signed-rank test was used for the paired comparison.

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TABLE I: Diagnostic Subgroups

	No. of Patients with Isolated Posteroinferior Instability	No. of Patients with Multidirectional Instability
No. of patients not receiving Workers' Compensation	17	5
No. of patients receiving Workers' Compensation	14	5
Total	31	10

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TABLE I: Diagnostic Subgroups

	No. of Patients with Isolated Posteroinferior Instability	No. of Patients with Multidirectional Instability
No. of patients not receiving Workers' Compensation	17	5
No. of patients receiving Workers' Compensation	14	5
Total	31	10

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TABLE II: Comparison of the Results of Physical Examination

*P values were determined with the Wilcoxon signed-rank test. NS = not significant.

Test	Mean Score (and Standard Deviation)
Preoperative Examination (points)	Most Recent Follow-up Examination (points)	P Value*
Anterior drawer	1.7 ± 0.8	0.5 ± 0.6	0.0015
Posterior drawer	2.4 ± 0.6	0.5 ± 0.7	0.0002
Sulcus	2.3 ± 0.7	0.5 ± 0.7	0.0002
Jerk	2.5 ± 0.7	0.2 ± 0.6	<0.0001
Crank	0.8 ± 0.9	0 ± 0	0.0022
Flexibility	0.9 ± 0.3	1 ± 0.1	NS

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TABLE II: Comparison of the Results of Physical Examination

*P values were determined with the Wilcoxon signed-rank test. NS = not significant.

Test	Mean Score (and Standard Deviation)
Preoperative Examination (points)	Most Recent Follow-up Examination (points)	P Value*
Anterior drawer	1.7 ± 0.8	0.5 ± 0.6	0.0015
Posterior drawer	2.4 ± 0.6	0.5 ± 0.7	0.0002
Sulcus	2.3 ± 0.7	0.5 ± 0.7	0.0002
Jerk	2.5 ± 0.7	0.2 ± 0.6	<0.0001
Crank	0.8 ± 0.9	0 ± 0	0.0022
Flexibility	0.9 ± 0.3	1 ± 0.1	NS

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Forty-one consecutive patients who had primary posteroinferior instability of the shoulder were evaluated. There were twenty-one male patients and twenty female patients, and the mean age was twenty-eight years at the time of the repair. One patient had bilateral involvement. The patients were followed for a mean of twenty-eight months (range, twelve to sixty-nine months). Ten patients had concomitant multidirectional instability. All of the patients had a clinically positive finding on the jerk test⁴, and they had had a minimum of six months of rehabilitation that failed. The reason for surgery was a clear perception of posterior instability with clinically identifiable posterior instability. The instability had been precipitated by an injury in thirty-two patients (78 percent). Nineteen patients (46 percent) were receiving Workers' Compensation (Table I). Nine patients had had previous surgery to treat the instability: three had had repair of a Bankart lesion, five had had a capsular shift, and one had had a posterior bone-block. In total, twenty patients (49 percent) had had previous shoulder surgery.

All of the patients were managed with an arthroscopic shift of the redundant posteroinferior aspect of the capsule to the adjacent labrum in order to augment the glenolabral concavity and concomitantly reduce capsular laxity. The one-time evaluation following the procedure included motion and stability examinations, the Simple Shoulder Test, the Short Form-36 Health Survey (SF-36), and a postoperative questionnaire formulated specifically for assessing the outcome of this treatment. The posterior flexibility-stiffness ratio, which is the ratio of the range of motion of the affected shoulder to that of the unaffected shoulder, was determined with use of a previously published formula¹⁴: (forward elevation ratio + cross-body adduction ratio + internal rotation to the back ratio)/3. The number of positive responses on the Simple Shoulder Test^9,18,20-22, a shoulder-specific self-assessment tool that has been shown to be reproducible, sensitive, and practical, was recorded for each individual. The SF-36^{9,18,20-22,32,33}, a familiar, thirty-six-item, standardized health-status self-assessment questionnaire, was scored according to the eight parameters described by Ware et al.³³. These include physical function, social function, physical role function, emotional role function, comfort, vitality, mental health, and general health perception. Because of the age and gender dependency of the SF-36 parameters, the raw scores were expressed as a percentage of matched population-based control values²⁸. The postoperative questionnaire formulated specifically for this treatment included questions on comorbidities, Workers' Compensation status, perception of operative success, change in pain level, postoperative stability of the shoulder, and persistence of any residual stiffness.

Operative Technique

A complete examination of the motion, laxity, and stability of the involved shoulder is performed with the patient under anesthesia, and the findings are compared with those of the contralateral side and with those of the preoperative examination in the office (Table II). Six ranges of motion were examined: humerothoracic motion, forward elevation, external rotation at the side, external rotation in abduction, internal rotation in abduction, and cross-body adduction. Internal rotation behind the back was recorded preoperatively. Laxity was assessed with the anterior and posterior drawer, inferior sulcus, and load and shift tests. Stability tests included the crank test for anterior stability and the jerk test for posterior stability. To perform the crank test, the examiner positions the arm in 90 degrees of abduction and 90 degrees of external rotation and pushes on the posterior aspect of the humeral head with his or her thumb to create anterior translation. The test is performed at a variety of elevations to determine maximum anterior translation, and it is considered to be positive when there is translation over the anterior aspect of the glenoid rim causing apprehension. To perform the jerk test, the arm is positioned at 90 degrees of elevation in the sagittal plane with full internal rotation⁴. Pressure is applied at the elbow while the scapula is forcibly stabilized to cause the humeral head to displace posteriorly relative to the glenoid. While the humeral head is posteriorly subluxated, the arm is abducted toward the coronal plane. When a patient has posteroinferior instability, palpable reduction of the humeral head into the glenoid fossa causes a jerk or clunk that is recognized by the examiner and the patient. Posterior translation may also be accompanied by a crepitant pop as the humeral head passes over the torn labral rim. The degree of translation was quantitated with use of a subjective scale ranging from 0 to 4 points, with 0 points indicating no translation; 1 point, translation up to the glenoid rim; 2 points, translation onto the glenoid rim; 3 points, translation over the glenoid rim; and 4 points, dislocation requiring manipulative reduction. Each patient had a jerk when examined under anesthesia and translation that was equivalent to or greater than that clinically demonstrated in the office.

In the operating room, the patient is placed in the beach-chair position. After the arthroscope is introduced into the glenohumeral joint through a posterior portal, the biceps and the rotator cuff are examined to ensure that they are intact. Then the rotator interval capsule, anterior glenohumeral ligaments, anterior and posterior inferior capsular recesses, and entire labral rim as well as its attachment to the glenoid articular cartilage are examined.

The posteroinferior quadrant is carefully examined and photographed to show the glenoid articular cartilage, the labral attachment, and the peripheral capsule and synovial tissue. The integrity and capacity of the posteroinferior capsuloligamentous recess is examined. A large-bore screw-in cannula (through which a standard 45-degree angled suture-hook will pass) is positioned in the posterior portal.

When the residual annular labral fibers are well attached to the articular glenoid rim, a motorized synovial resector blade is inserted and the peripheral rim of the labrum is lightly abraded to a bleeding surface from six o'clock to nine o'clock around the posteroinferior quadrant. A 45-degree angled suture-hook is inserted into the interior recess and is used to puncture through the inferior aspect of the capsule one centimeter peripheral to the glenoid labrum. The capsule is shifted posterosuperiorly (translating medially and superiorly) a maximum of one centimeter in shoulders with a large capsular recess. The suture-hook is passed through the junction of the annular labral fibers where they join the articular cartilage rim (Fig. 1). A number-0 PDS (polydioxanone) monofilament absorbable suture is advanced through the suture-hook into the joint for an extended length. Next, the suture-hook is removed with use of rotation in the opposite direction of that used on insertion. The PDS suture is retrieved and tied securely to pull the peripheral aspect of the capsule onto the articular glenoid labrum. Three, four, or five number-0 PDS sutures are placed through the capsule around the rim of the glenoid labrum to augment the depth of the glenolabral fossa with the rolled-up layer of capsule (Fig. 2).

In patients with ligamentous hyperlaxity (anterior, posterior, and inferior translation of grade 2 or more), an anterior and posterior capsulolabral augmentation is performed and the rotator interval capsule is plicated (in shoulders with a gap of more than one centimeter, as measured with a graduated probe, adjacent to the glenoid). To plicate the rotator interval, sutures are passed through the margins of the capsule while the subacromial space is viewed. After the arthroscope has been inserted into the subacromial space, the anterosuperior cannula is retracted from the glenohumeral joint. The gap in the rotator interval capsule is visualized, and a 30-degree suture-hook (or another kind, if preferred) is first passed through the rotator interval capsule superior to the upper rolled border of the subscapularis. Next, the hook is advanced through the leading edge of capsule that is attached to the anterior border of the supraspinatus. The rotator interval is closed by passing the PDS suture through either the anterior or the lateral subacromial portal and tying it arthroscopically. Additional PDS sutures are placed farther medially and laterally to plicate the rotator interval capsule (Fig. 3-A and Fig. 3-B). All knots are tied in the subacromial space.

After surgery, the shoulder is placed in a soft pillow sling for a total of three weeks. Isometric internal and external rotation and abduction-strengthening exercises are begun immediately. Two to three weeks after the surgical procedure, active-assisted elevation in the scapular plane and external rotation with the arm at the side are allowed to the limit of comfort. Patients are advised not to push, pull, or lift until six weeks after the repair. By four weeks after the repair, most patients are able to achieve a minimum of 90 degrees of elevation and 40 degrees of external rotation with the arm at the side. After six weeks, patients begin unlimited active-assisted forward elevation, external rotation with the arm at the side, and internal rotation behind the back (avoiding cross-body adduction). The goal is to recover a nearly full range of motion especially before the patient returns to sports activities. Internal-external rotation, flexion-extension, and abduction-strengthening exercises against progressive resistance are begun as the range approaches normal. Patients with multidirectional instability are not allowed to begin motion until four weeks after the repair, and they should always avoid stretching exercises since motion will be recovered with normal active use. Strengthening of the rotator cuff and the deltoid is most critical in patients with multidirectional instability. Recovery of normal flexibility and range of motion is of primary importance in patients with unidirectional posteroinferior instability.

Results

Introduction | Materials and Methods | Results | Discussion | References

Arthroscopic Findings

Thirty-four patients (83 percent) had lesions affecting the posteroinferior aspect of the glenolabral concavity. We classified these lesions into four categories: labral detachment (five patients; 12 percent), chondral or labral erosion (seven patients; 17 percent), capsular and synovial stripping (nine patients; 22 percent), and a labral split or tear (thirteen patients; 32 percent) (Fig. 4-A, Fig. 4-B, Fig. 4-C, and Fig. 4-D).

The diagnosis was isolated posteroinferior instability in thirty-one patients and concomitant multidirectional instability in ten patients (Table I). In addition to the capsulolabral augmentation, closure of the rotator interval was performed in nine of the ten patients with multidirectional instability. The mean number of sutures (and standard deviation) used in these shoulders was 4.5 ± 1.

Physical Examination

The findings at the preoperative physical examination were compared with those at the latest follow-up examination (Table II). Stability had improved significantly in all of the shoulders, with the results of the jerk test showing the most improvement (p < 0.0001). The findings on the latest physical examination demonstrated that the flexibility-stiffness ratio had not changed significantly after the operation.

Shoulder Function, Health Status, and Patients' Perceptions

Overall, the patients had a wide variation in preoperative function according to the Simple Shoulder Test, with some patients able to perform all twelve functions and some unable to perform any of them (Fig. 5 and Fig. 6). The mean score (and standard deviation) on the test improved significantly from 5.5 ± 3.4 points preoperatively to 8.1 ± 3.3 points at the most recent postoperative examination (Wilcoxon signed-rank test, p = 0.0023). The nineteen patients who were receiving Workers' Compensation did not demonstrate a significant improvement in any of the functions on the Simple Shoulder Test.

The preoperative health status was most compromised in the domains of comfort and physical role function. Postoperatively, there was significant improvement in comfort (Wilcoxon signed-rank test, p = 0.015) and physical function (Wilcoxon signed-rank test, p = 0.036) (Fig. 7). The twenty-two patients who were not receiving Workers' Compensation demonstrated a significant improvement in physical function (Wilcoxon signed-rank test, p = 0.015), physical role function (Wilcoxon signed-rank test, p = 0.04), and comfort (Wilcoxon signed-rank test, p = 0.012) (Fig. 8). The nineteen patients who were receiving Workers' Compensation had no significant improvement in any of the SF-36 categories.

Only twenty-four patients (59 percent) said that they had had no instability postoperatively; this included nine of the nineteen patients who were receiving Workers' Compensation and fifteen of the twenty-two patients who were not. However, thirty-five patients (85 percent) - fifteen who were receiving Workers' Compensation and twenty who were not - had improved stability (a negative result on the jerk test) after surgery. Residual stiffness was perceived by twenty-eight patients (68 percent), which included fifteen who were receiving Workers' Compensation and thirteen who were not. Six of the nineteen patients receiving Workers' Compensation and twenty-one of the twenty-two who were not returned to work (p = 0.0005).

The nine patients who had a revision procedure did not have a good success rate. The mean score (and standard deviation) on the Simple Shoulder Test increased from 5.2 ± 3.9 points to 6.9 ± 4.2 points, which was not found to be significant. Only two of the nine patients had no postoperative instability, and seven of the nine said that the shoulder felt stiffer. Despite the worse functional outcomes in this population, six of the nine returned to work. (Only one of the nine patients was receiving Workers' Compensation.)

Thirty-five patients (85 percent) stated that they would have the procedure again and would recommend the procedure to another person.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

Previous studies have demonstrated that posterior instability is associated with lax posteroinferior capsular ligaments and damage to the rotator interval^23,24,26. Some studies have demonstrated the importance of the inferior glenohumeral ligament complex in stabilizing the shoulder with the arm in various positions²⁵. In cadaveric studies, Bigliani et al.¹ and Weber and Caspari³⁵ demonstrated plastic deformation of the inferior glenohumeral ligament complex during rapid loading. Warren et al. suggested the importance of the superior glenohumeral ligament in preventing posterior instability³⁴. Blasier et al. pointed out that the subscapularis muscle contributed a great deal to stabilization against a posterior subluxation force⁴. In addition, the coracohumeral ligament was an effective contributor in neutral humeral rotation, and the inferior glenohumeral ligament was an effective contributor in internal humeral rotation. One of us (D. T. H., II) and colleagues emphasized the role of the capsuloligamentous integrity of the rotator interval in resisting pathological posteroinferior translation of the humeral head¹³.

The posterior aspect of the labrum has also been implicated in posterior instability. The reverse Bankart lesion, although rare, has been described^8,27,30,31. A previous study from our institution demonstrated that the labrum contributes approximately 20 percent of the concavity-compression stabilization of the glenohumeral joint in the inferior and the posteroinferior direction¹⁹. Other investigators have concurred that the posterior part of the labrum may provide a substantial degree of stability against posterior migration of the humeral head^10,12.

In the present study, we found that, in addition to capsular laxity, one of four easily recognized lesions of the glenolabral concavity is present in the majority of patients with posteroinferior instability of the shoulder. These lesions provide visual evidence of repetitive pathological translation of the humeral head in the posteroinferior quadrant. The pathological lesions included stripping of the capsule and synovial tissue; erosion of the cartilage or labrum; splitting, fraying, or tearing of the labrum; and complete detachment of the labrum with or without a chondral rim defect.

The initial treatment for this condition has always consisted of an intensive course of physical therapy with strengthening exercises. Although shoulders with posteroinferior instability respond to muscle-strengthening more readily than do shoulders with anterior instability, a certain percentage of unstable shoulders do not improve with this treatment^{7,11,15,17,27,31}. Open surgical treatment of this abnormality has varied from posterior capsular procedures (the reverse Putti-Platt¹⁷, reverse Bankart repair, posteroinferior capsular shift, and Boyd-Sisk procedures) to osseous reconstruction in the form of glenoid osteotomy, bone blocks, or a combination of soft-tissue and osseous procedures^{2,5,6,11,16,24,27,30}. These operations have had varied results. Recent investigators have stressed the importance of addressing the capsular redundancy in the posteroinferior region^2,11,27,31. In addition, Wolf and Eakin, in a retrospective study of fourteen patients, introduced a method of arthroscopic repair, identical to the one used in our study, that addressed the posteroinferior capsular redundancy and increased the depth of the glenolabral concavity with a capsulolabral augmentation³⁶.

Our results indicate that arthroscopic plication to reduce excessive capsular laxity of the redundant posteroinferior aspect of the capsule together with capsulolabral augmentation to restore the depth of the glenolabral concavity is an effective method of eliminating or significantly reducing symptomatic posteroinferior instability. In addition, the patient's perceived success of this procedure seems to be affected by his or her Workers' Compensation status.

Posteroinferior instability of the shoulder is associated not only with capsular laxity but also with well defined lesions of the glenolabral concavity. Arthroscopic capsular plication to reduce excessive capsular laxity of the redundant posteroinferior aspect of the capsule along with capsulolabral augmentation to restore the depth of the glenolabral concavity has proved to be an effective method of treatment after a mean duration of follow-up of twenty-eight months.

References

Introduction | Materials and Methods | Results | Discussion | References

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Topics

perception ; sutures ; worker's compensation ; shoulder region ; erosion ; sf-36

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John Antoniou, David T. Duckworth, Douglas T. HarrymanII; Capsulolabral Augmentation for the Management of Posteroinferior Instability of the Shoulder*. The Journal of Bone & Joint Surgery. 2000 Sep;82(9):1220-1220.

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