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The Journal of Bone and Joint Surgery 78:246-60 (1996)
© 1996 The Journal of Bone and Joint Surgery, Inc.

The Capsular Imbrication Procedure for Recurrent Anterior Instability of the Shoulder*{dagger}

MICHAEL A. WIRTH, M.D.{ddagger}, GEORGE BLATTER, M.D.§ and CHARLES A. ROCKWOOD, JR., M.D.{ddagger}, SAN ANTONIO, TEXAS

Investigation performed at the Department of Orthopaedics, University of Texas Health Science Center at San Antonio, San Antonio


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Operative Technique
 Results
 Discussion
 References
 
One hundred and thirty-eight patients (142 shoulders) who had recurrent anterior instability of the shoulder that was unresponsive to a specific physician-directed rehabilitation program were managed with an anatomical capsular imbrication reconstruction. The procedure included repair of the capsulolabral injury, when present, and reinforcement of the anteroinferior capsular ligaments with an imbrication technique that decreases the over-all capsular volume. The shoulders were divided into two groups: 108 shoulders in which the recurrent instability was related to a defined traumatic episode (Group I) and thirty-four shoulders with no distinct history of trauma (Group II). The anatomical capsular imbrication was the primary procedure in ninety shoulders and was used to treat at least one failed previous reconstruction in fifty-two shoulders. According to the grading system of Rowe et al., 93 per cent (132) of the shoulders had a good or excellent result at an average of five years (range, two to twelve years) after the operation. The results after a previous failed reconstruction were especially encouraging. Of the fifty-two shoulders that had had at least one previous reconstructive procedure, forty had an excellent result, five had a good result, four had a fair result, and three had a poor result. The results of this study suggest that this procedure restores stability while preserving a functional range of motion in patients who have symptomatic recurrent anterior instability of the shoulder, regardless of the etiology.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Operative Technique
 Results
 Discussion
 References
 
Operative stabilization of anterior glenohumeral instability is indicated for the treatment of recurrent instability that fails to respond to a rehabilitation program that was directed by a physician. The literature is replete with various operative techniques, and this suggests a lack of consensus with regard to the underlying abnormality2-4,8,9,11,12,14,18-20,25-27,29,31,33,39,41,42,45-47,49,51,55,58,60,62.

A number of problems have been identified after some operative procedures, including restricted glenohumeral motion23,32,37,52,63,64, posterior subluxation of the glenohumeral joint32,37,52,63,64, and late glenohumeral osteoarthrosis23,32,37,52,63,64. Some of these complications are due to the fact that a number of proposed operative procedures do not directly address the pathological condition found in the glenohumeral capsule and labrum16,24,27,28,32,34-38,44,48,51,52,56,58,64.

Since 1978, we have used an operative approach developed by the senior one of us (C. A. R., Jr.) that directly addresses the anatomical source of the recurrent anterior glenohumeral instability. The operation is designed to repair the capsulolabral injury as well as to reduce the over-all volume of the capsule. The purpose of this report is to describe the results of this method of anterior reconstruction in a series of 142 shoulders.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Operative Technique
 Results
 Discussion
 References
 
One hundred and seventy-eight patients (182 shoulders) were managed by the senior one of us (C. A. R., Jr.), between 1980 and 1990, for recurrent anterior instability of the shoulder on the shoulder service of the University of Texas Health Science Center at San Antonio with use of an anatomical capsular imbrication procedure. Patients who had recurrent anterior instability associated with glenoid hypoplasia, proximal motor-neuron disease, myelopathy, myopathy, injury of the brachial plexus, or a psychological disorder were excluded. All of the patients were managed operatively after a rehabilitation program that two of us (M. A. W. and C. A. R., Jr.) directed, which emphasized strengthening of the three parts of the deltoid, the muscles of the rotator cuff, and the scapula-stabilizing muscles, had failed. Additional non-operative measures included oral administration of anti-inflammatory medications as well as application of moist heat and modification of activity. Failure of the non-operative treatment was characterized by symptomatic recurrent anterior glenohumeral subluxation or dislocation as well as by apprehension on physical examination.

Of the 178 patients, twenty-four had been followed for less than two years and sixteen were lost to follow-up, leaving 138 patients (112 male and twenty-six female) and 142 shoulders available for long-term follow-up evaluation. The average age at the time of the operation was thirty years (range, fifteen to sixty-four years). There were sixty-nine right and seventy-three left shoulders; eighty-seven (61 per cent) were on the side of the dominant upper extremity.

The shoulders were divided into two groups on the basis of whether or not the anterior instability was the result of a traumatic event10,51. One hundred and eight shoulders had a defined association with a traumatic event (Group I), while thirty-four shoulders did not (Group II). Assignment into one of these two groups was based on a comprehensive medical history, physical examination, and evaluation of radiographs.

A traumatic etiology (Group I) was defined as a traumatic event followed by moderate or severe pain and subsequent recurrent unidirectional anterior instability. Additional information supporting the diagnosis included a mechanism of injury predominantly involving forceful abduction, extension, and external rotation of the shoulder associated with a sudden sharp pain and subjective numbness; the need for manipulative reduction; residual aching of the shoulder for several weeks; and radiographic evidence of frank dislocation, a posterolateral defect of the humeral head, calcification along the anteroinferior aspect of the glenoid, erosion or blunting of the anterior aspect of the glenoid rim, or fracture of the anterior aspect of the glenoid rim.

The diagnosis of recurrent atraumatic instability (Group II) was characterized by symptomatic anterior instability that had developed insidiously or after slight trauma in a patient who had evidence of multidirectional laxity of both shoulders on physical examination. Although these patients frequently attributed the onset or aggravation of symptoms to trauma, careful review of the history revealed that the original injury was minor, was associated with only mild pain, and characteristically involved minimally provocative activities such as throwing a ball, swinging a tennis racquet or golf club, or diving into a pool. Additional supporting evidence included spontaneous reduction of the subluxation or dislocation and the ability to continue to participate in sports activities without interruption.

Each group had an average of eight (range, one to 100) episodes of instability. These episodes were described by the patients as the times that the shoulder felt unstable or had dislocated, regardless of the need for assisted reduction. The average time from the onset of the instability to the reconstruction was thirty months (range, two months to twenty-five years) for the shoulders in Group I and sixty-one months (range, ten months to fifteen years) for those in Group II.

Group I
Group I comprised 106 patients (ninety-one male and fifteen female) (108 shoulders) who had an average age of thirty-one years (range, sixteen to sixty-four years). There were fifty-one right shoulders and fifty-seven left shoulders; sixty-five shoulders were on the side of the dominant extremity.

Twenty-eight patients participated in recreational athletics; seventeen, in high-school athletics; and ten, in collegiate athletics. Sixteen of these patients were involved in a sport that required overhead use of the extremity, which included baseball, softball, volleyball, and football (as a quarterback).

The diagnosis was recurrent dislocation in sixty-seven shoulders and recurrent subluxation in the remaining forty-one. Sixty shoulders that had recurrent dislocation necessitated the assistance of a physician, trainer, or coworker on at least one occasion to reduce the glenohumeral joint. All but three patients described a specific traumatic event that initiated the anterior instability of the shoulder. These three patients could not describe an event because of multiple trauma associated with a closed head injury. Sixty-two shoulders were injured during sports activity, twenty-seven shoulders sustained an occupational injury, thirteen shoulders were injured in a motor-vehicle or motorcycle accident, and three shoulders were injured during an altercation.

The mechanism of injury of fifty-two shoulders involved extension, abduction, and external rotation, with thirty of the fifty-two injuries associated with football, snow-skiing, basketball, gymnastics, or wrestling. Forty-six shoulders were injured by a direct force to the shoulder, with thirty-two of these injuries occurring during sports activity. Five injuries were the result of a fall from a height of less than six feet (1.8 meters) and six, a fall from a height of more than six feet; direct contact of the shoulder with the ground at the time of impact contributed to five of these injuries, while six were the result of an axial load to the outstretched and abducted upper extremity. Traction to the upper extremity accounted for the injury of ten shoulders; nine of these injuries were in oil-field workers and were usually the result of clothing becoming caught in power equipment.

Of the 108 shoulders in Group I, thirty-two had had an average of two (range, one to six) previous operations, including a capsulorrhaphy (seven shoulders), an acromioplasty (two), an excision of the distal aspect of the clavicle (two), a DuToit procedure (three), a Putti-Platt procedure (five), a Magnuson-Stack procedure (six), a Bankart procedure (three), a Bristow procedure (ten), a glenoid osteotomy (one), an arthroscopic procedure (eight), removal of the hardware related to a failed previous reconstruction (eleven), and an unspecified procedure (seven).

Between episodes of instability, eighty-five patients reported slight or no pain with activity, fifteen had pain with overhead work or sports activities, and six had mild discomfort at rest. All had moderate or marked discomfort with the episodes of instability.

Eighteen patients had subjective numbness or tingling associated with pain in the involved extremity. These paresthesias were not in any particular dermatomal distribution, but they were characterized by a sudden sharp or disabling pain at the time of the injury and were often associated with transient weakness and loss of control of the upper extremity.

The active range of motion was measured for overhead elevation (the position between abduction and forward flexion that allowed the highest excursion) and internal rotation with the patient sitting or standing. Active external rotation was determined with the elbow at the side. For the seventy-six shoulders that had not had previous operative intervention, the mean range of motion was 173 degrees (range, 130 to 180 degrees) of elevation, 51 degrees (range, 30 to 80 degrees) of external rotation, and internal rotation to the spinous process of the eighth thoracic vertebra (range, the fifth lumbar to the fourth thoracic vertebra). For the thirty-two shoulders in which a previous operation had failed, the mean range of motion was 169 degrees (range, 130 to 175 degrees) of elevation, 39 degrees (range, 0 to 75 degrees) of external rotation, and internal rotation to the spinous process of the ninth thoracic vertebra (range, the fifth lumbar to the sixth thoracic vertebra).

All patients demonstrated apprehension when the involved shoulder was subjected to an anteriorly directed force by abduction and external rotation of the upper extremity. No patient demonstrated apprehension with inferior or posterior instability testing, although twenty-three patients demonstrated a positive sulcus sign with inferior drawer testing of both shoulders. These patients also demonstrated hyperextension of the metacarpophalangeal joints, hyperabduction of the thumb, and recurvatum of the knees and elbows, consistent with a diagnosis of generalized ligamentous laxity.

The strength of the shoulder in elevation and external rotation with the arm at the side was evaluated manually according to the grading system of the American Shoulder and Elbow Surgeons evaluation form5. Preoperatively, strength was graded as normal in seven shoulders, good in seventy-six, fair in nineteen, and poor in six. Eighty-five shoulders were graded as causing the patient difficulty, or a more severe disability, with the performance of at least five of the fifteen activities of daily living listed on the evaluation form. The function of the remaining twenty-three shoulders was graded as mildly compromised with regard to the performance of at least five of these activities.

Group II
Group II comprised thirty-two patients (twenty-one male and eleven female) (thirty-four shoulders) who had an average age of twenty-seven years (range, fifteen to forty-five years). There were eighteen right and sixteen left shoulders; twenty-two shoulders were on the side of the dominant upper extremity.

Eight patients participated in recreational athletics; four, in high-school athletics; and three, in collegiate athletics. Eight of these patients were involved in sports requiring overhead use of the limb, including swimming (three), volleyball (two), and softball, baseball, and tennis (one each). Twenty-six patients (twenty-eight shoulders) attributed the onset of recurrent instability to an atraumatic event such as diving into a pool, swinging a tennis racquet or a golf club, or running a pass pattern on the football field. The remaining six patients could not attribute the onset of the symptomatic instability to any specific event. In these patients, the symptoms developed gradually in association with activities such as gymnastics, volleyball, swimming, and tennis.

Twenty shoulders had had an average of two (range, one to six) previous operations, including a capsulorrhaphy (five), a Putti-Platt procedure (six), a Magnuson-Stack procedure (ten), a Bankart procedure (two), a Bristow procedure (five), a glenoid osteotomy (one), an arthroscopic procedure (five), removal of hardware from a failed previous reconstruction (two), an excision of the distal aspect of the clavicle (one), a manipulation secondary to limited motion following a Magnuson-Stack procedure (one), and an unspecified procedure (seven).

Between episodes of instability, thirteen patients had no or slight pain and nineteen had aching discomfort with simple activities or at rest. Twenty-five of the patients had mild or moderate pain with the episodes of instability.

Ten patients had a history of numbness or tingling in the involved extremity during episodes of instability. The initial subluxation or dislocation had been followed by spontaneous reduction in thirty-one shoulders, and three shoulders were reduced with the help of someone other than the patient. For ten of the patients in whom the initial injury was followed by spontaneous reduction, repetitive episodes of instability commonly increased the instability to the extent that dislocation occurred and closed reduction was necessary. Nine of these patients learned various manipulative techniques that allowed them to reduce the shoulder themselves.

For the fourteen shoulders that had not had a previous operation, the mean range of motion was 178 degrees (range, 160 to 190 degrees) of elevation, 69 degrees (range, 20 to 90 degrees) of external rotation, and internal rotation to the spinous process of the fifth thoracic vertebra (range, the twelfth thoracic to the second thoracic vertebra). For the twenty shoulders that had had at least one previous operation, the mean range of motion was 164 degrees (range, 140 to 190 degrees) of elevation, 58 degrees (range, -30 to 90 degrees) of external rotation, and internal rotation to the spinous process of the seventh thoracic vertebra (range, the first lumbar to the fourth thoracic vertebra).

All patients demonstrated a positive apprehension test when the involved shoulder was subjected to an anteriorly directed force. A positive sulcus sign was present with inferior drawer testing of both shoulders in each patient. With posterior drawer testing, the humeral head could be translated more than 50 per cent of its diameter from its articulation with the glenoid in both shoulders of all patients. All patients demonstrated evidence of generalized ligamentous laxity with hyperextension of the metacarpophalangeal joints, hyperabduction of the thumb, and recurvatum of the knees and elbows.

The strength in elevation and external rotation with the arm at the side was graded5 as normal in three shoulders, good in twelve, fair in fifteen, and poor in four. Twenty-nine shoulders were graded as causing difficulty or a more severe disability during the performance of at least five of the fifteen activities of daily living; the remaining five shoulders caused a mild compromise of function during at least five of these activities5.

Radiographic Findings
Anteroposterior, axillary lateral, modified axillary (the so-called West Point axillary lateral53), and Stryker notch radiographs22,37,52 were made for all patients. More recently, an apical oblique radiograph, as described by Garth et al.21, was made to identify anteroinferior calcification or fractures of the glenoid rim.

Group I
A posterolateral defect of the humeral head (a Hill-Sachs lesion) was observed in forty-five (67 per cent) of the sixty-seven shoulders with recurrent dislocation. Additionally, twenty-two shoulders (33 per cent) were seen to have calcification along the anteroinferior aspect of the glenoid or erosion, blunting, or fracture of the anterior aspect of the glenoid rim. No Hill-Sachs lesions were observed in the forty-one shoulders with recurrent subluxation. However, calcification along the anteroinferior aspect of the glenoid or erosion, blunting, or fracture of the anterior aspect of the glenoid rim was seen in twenty-two shoulders (54 per cent) with use of a true axillary, a West Point axillary lateral53, or an apical oblique radiograph21.

An apical oblique radiograph was made for fifty-eight shoulders and demonstrated calcification along the anteroinferior aspect of the glenoid in nine. Early degenerative changes were noted in two shoulders that had had a previous operation. These changes were characterized by a slight decrease in the glenohumeral joint space and subtle flattening and subchondral sclerosis of the articular surface of the humeral head.

Group II
The radiographic findings in the patients who had atraumatic instability were limited to inferior subluxation of the glenohumeral joint evident on an anteroposterior radiograph, made with the patient standing, in three shoulders and early degenerative changes in two shoulders.

Operative Findings

Group I
A Perthes-Bankart lesion was found in fifty (46 per cent) of the 108 shoulders. Fifteen of these lesions involved less than one centimeter of capsulolabral detachment from the anterior aspect of the glenoid rim. The lesion was not repaired during the anatomical capsular imbrication procedure in these fifteen shoulders, as this degree of labral detachment was not thought to be important. Of the remaining thirty-five lesions, twenty-one involved one to two centimeters of capsulolabral stripping and fourteen involved more than two centimeters. In all thirty-five shoulders, the recurrent instability was treated with repair of the capsulolabral injury and the anatomical capsular imbrication procedure.

Multiple loose bodies were present in ten shoulders. Avulsion of the subscapularis tendon from the lesser tuberosity was found in seven shoulders, and a musculotendinous tear of the distal half of the subscapularis muscle was seen in five shoulders. The glenoid labrum was torn or frayed in thirty-eight shoulders, four of which had a bucket-handle tear. The anterior aspect of the capsule was torn or ruptured in ten shoulders. Defects of the anterior aspect of the glenoid were noted in thirty-two shoulders. Erosion of the anterior and inferior portion of the glenoid rim or a loss of bone involving as much as 10 per cent of the articular surface accounted for all but four of these defects. Of the remaining four defects, three consisted of damage to the articular cartilage on 10 to 25 per cent of the anterior aspect of the glenoid and one, damage to the articular cartilage on the anterior half of the glenoid.

Early degenerative changes consisting of grade-I or II chondromalacia (irregular fibrillated areas of cartilage) involving the glenoid and humeral head were seen in eight shoulders. Moderate degenerative changes characterized by grade-III chondromalacia (areas of fissuring and focal erosive cartilage lesions) were noted in two shoulders, one of which had had six previous procedures. A Hill-Sachs lesion was noted in sixty-five shoulders; none of the lesions involved more than one-third of the diameter of the humeral head.

Group II
Capsular abnormalities were the major pathological finding and included tears of the glenohumeral ligaments, thinning of the capsule, and capsular redundancy in thirty-two shoulders. By definition, a Perthes-Bankart lesion excluded patients from this group, as it is our opinion that this lesion results from trauma to the anterior aspect of the shoulder. Minor labral abnormalities were noted in eighteen shoulders and included anterior labral fraying in eight and a hypoplastic or absent labrum in ten. The inferior third of the subscapularis was atrophic or torn in five of the shoulders that had had a previous operation. One shoulder had early degenerative changes of grade-I to II chondromalacia, and two had moderate degenerative changes of grade-III chondromalacia involving the glenoid and humeral head. All three of these shoulders had had at least one previous operation.


   Operative Technique
Top
 Abstract
 Introduction
 Materials and Methods
 Operative Technique
Results
 Discussion
 References
 
The operative technique has been described previously by the senior one of us (C. A. R., Jr.)37,51,52. The standard anterior axillary incision begins in the anterior axillary crease, extending proximally toward and usually stopping at the coracoid process. In large muscular men, the incision may extend proximally as far as the clavicle. In women, the modified axillary incision, as described by Leslie and Ryan30, is used. The skin is undermined subcutaneously in the proximal-medial and distal-lateral corners, so as to expose the deltopectoral interval. Usually, this interval is identified by the cephalic vein, which may be absent or lying deep in the interval out of sight. The deltopectoral interval is developed all the way up to the clavicle, and there is no need to detach any of the deltoid from the clavicle. With the deltopectoral muscles retracted out of the way, the clavipectoral fascia is seen covering the conjoined tendons and is divided vertically along the lateral border of the conjoined tendons. Before a Richardson retractor is placed in the medial side of the incision to retract the conjoined muscles and pectoralis major muscle, the location of the musculocutaneous nerve as it enters the conjoined tendon should be identified. Usually, the entrance of this nerve can be felt by palpating just medial to the conjoined tendon and muscles.

Next, the axillary nerve is identified as it passes along the anterior border of the subscapularis muscle and is protected with a Scofield retractor. With the arm in external rotation, the superior and inferior borders of the subscapularis tendon can be visualized and palpated. The sulcus at the superior border of the subscapularis tendon is the interval between the subscapularis and supraspinatus tendons. The proximal two-thirds of the subscapularis tendon is carefully transected in a vertical direction, down to but not into the capsule. This incision is made two centimeters medial to its insertion into the lesser tuberosity (Fig. 1). Maintaining the distal third of the subscapularis tendon prevents injury to the anterior humeral circumflex artery and veins, which lie on the anterior surface of the distal portion of the subscapularis. The anterior humeral circumflex artery is the primary blood supply to the head of the humerus and should be preserved. Once the vertical cut in the tendon has been completed, the medial part of the tendon is reflected off the capsule, with the use of curved Mayo scissors, until there are no additional connections between the tendon and the capsule (Fig. 2). If the capsule is especially thin, we try to leave a little of the subscapularis tendon on the capsule to add to its strength. The muscle should be freed circumferentially until there are no adhesions to the underlying capsule or to the deep surface of the coracoid process. When lateral traction is applied on the tendon, the tendon should have an elastic feel. Three or four stay sutures of number-2 Cottony Dacron (Deknatel, Fall River, Massachusetts) are placed in the medial edge of the tendon; these are used initially for retraction and later at the time of the repair of the tendon. The lateral stump of the subscapularis tendon is reflected off the capsule with a small sharp knife to facilitate the subsequent reapproximation of the tendon after the capsule has been repaired. This is rather easy to perform with the capsule intact and taut when the arm is held in external rotation and is difficult when the capsule has been divided. Failure to perform this step obscures visualization of the lateral aspect of the capsule and creates a more difficult two-layer closure of the capsule and the subscapularis tendon.



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  		Figs. 1 through 9: Illustrations demonstrating the operative technique. Fig. 1: The proximal two-thirds of the subscapularis tendon is divided vertically. Preservation of the distal third of the tendon prevents injury to the anterior circumflex vessels and axillary nerve.

 


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  		Axial view, demonstrating the intended plane of dissection for reflection of the medial and lateral portions of the subscapularis tendon.

 
With the divided portions of the subscapularis tendon reflected medially and laterally and with the arm in external rotation, attention is directed to the intact distal third of the subscapularis tendon. An elevator is used to strip the section of the subscapularis muscle-tendon unit gently off the anteroinferior aspect of the capsule. A narrow deep retractor (such as a Scofield retractor) should be used to retract the distal part of the subscapularis muscle anteriorly and distally, which allows for easy visualization of the inferior aspect of the capsule. The retractor holds not only the distal part of the subscapularis muscle but also the axillary nerve anteriorly and distally out of the way, preventing injury when the inferior aspect of the capsule is divided and repaired (Fig. 3).



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  		The inferior aspect of the capsule is exposed, and the axillary nerve is protected.

 
Next, the capsule is divided vertically, midway between its attachment on the glenoid rim and the humeral head. This incision begins at the capsular rotator interval or the superior glenohumeral ligament and extends all the way down to the most inferior aspect of the capsule. Occasionally, the superior capsular region is incompetent, but this does not alter the vertical capsular incision. We have found that it is easier to divide the capsule midway between its attachments to the humeral head and glenoid for several reasons. First, this method is technically easier than release of the capsule from the glenoid rim, where medial exposure is more difficult. Second, it improves medial visibility and access to the glenoid rim for repair of a Perthes-Bankart lesion. Finally, it allows double-breasting of the glenohumeral ligaments in the characteristically thin region of the anteroinferior aspect of the capsule. Horizontal sutures are placed in the medial aspect of the capsule, inferior to superior, with number-2 Dacron ligature. The joint is carefully explored for loose bodies, labral tears, chondromalacia, and other intra-articular abnormalities. Close attention should be paid to stripping of the labrum, capsule, and periosteum off their normal attachments on the glenoid rim and the neck of the scapula.

If the capsule is securely fixed to the glenoid rim, the capsular reconstruction is performed. However, if stripping of the capsule and periosteum off the glenoid rim and the neck of the scapula created a defect of more than five millimeters, the capsule must first be reattached before it is reconstructed. The anterior aspect of the glenoid rim and the neck of the scapula is decorticated with an osteotome or air burr (Fig. 4). Usually, three holes are made with a small drill-bit between three and six o'clock on the anterior articular surface of the glenoid, approximately three to four millimeters posterior to the rim. Next, a curved Carter Rowe awl and tenaculum are used to connect the drill-holes with the anterior aspect of the decorticated neck of the glenoid. Non-absorbable number-2 Dacron sutures are passed through these holes so that there are two loops of intra-articular sutures through the three holes (the center hole has two sutures through it) (Fig. 5). The medial aspect of the capsule is pulled laterally, and the needles on the intra-articular loops of suture are passed up and through the medial aspect of the capsule (Fig. 6). These sutures are then tied, securing the capsule to the raw bone of the glenoid rim. After the medial aspect of the capsule is secured back to the glenoid rim, it is double-breasted laterally and superiorly under the lateral aspect of the capsule. The extent of the anteroinferior capsular laxity determines the degree of imbrication necessary to reduce the glenohumeral joint. In shoulders with a large degree of anteroinferior capsular laxity, the medial aspect of the capsule is often shifted ten to fifteen millimeters medially and superiorly and is imbricated for a distance of fifteen to twenty millimeters by the lateral aspect of the capsule. When there is a lesion in the superior aspect of the capsule, it is closed with a purse-string suture repair before the medial capsular imbrication is performed (Fig. 7). All of the sutures are placed and tied with the arm held in 20 to 25 degrees of external rotation and 20 to 30 degrees of abduction. Next, the lateral aspect of the capsule is double-breasted by taking it medially and superiorly and suturing it down to the anterior surface of the medial aspect of the capsule (Figs. 8-A and 8-B). These sutures are also placed with the arm in 20 to 25 degrees of external rotation and abduction. This type of capsular reconstruction not only eliminates all of the laxity in the anterior and inferior capsular ligaments but also is much stronger because of the double-breasting of the stretched and thinned out capsule. The wound is carefully irrigated with several liters of saline solution. The two borders of the subscapularis tendon are reapproximated with the previously placed one-millimeter Dacron suture (Fig. 9). The deep subcuticular tissues and deltoid muscle are infiltrated with twenty to twenty-five milliliters of 0.25 per cent Marcaine (bupivacaine). The deep subcutaneous layer is closed with 2-0 non-absorbable sutures, which helps to prevent widening of the scar. The subcutaneous fat is closed with absorbable sutures, and a running 2-0 subcuticular Prolene (polypropylene) suture is used for final skin closure.



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  		The anterior aspect of the glenoid is decorticated.

 


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  		Non-absorbable sutures are passed through the drill-holes for subsequent repair of the Perthes-Bankart lesion.

 


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  		The medial aspect of the capsule is pulled taut in a lateral direction, and the suture is passed through the capsule.

 


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  		Any superior capsular defect is closed, followed by superolateral shift of the medial capsular leaflet.

 


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  		Figs. 8-A and 8-B: The lateral capsular leaflet is shifted superomedially, which double-breasts the anterior aspect of the capsule.

 


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  		Figs. 8-A and 8-B: The lateral capsular leaflet is shifted superomedially, which double-breasts the anterior aspect of the capsule.

 


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  		The subscapularis tendon is reapproximated.

 

Postoperative Care
On the afternoon of the day of the operation, the shoulder immobilizer is removed and the flexed elbow is extended onto the bed. This is followed by a careful neurological examination of the radial, ulnar, median, musculocutaneous, and axillary nerves. With the patient supine, the surgeon gently passively flexes the arm to as much as 90 degrees, demonstrating to the patient that the arm can be gently moved without harming the repair. On the first postoperative day, the patient is instructed about gentle pendulum exercises and how to use the normal arm for passive flexion exercises of the treated shoulder. Passive flexion exercises are permitted to an elevation of 90 degrees in sets of five repetitions and at a frequency of four to six times a day. The shoulder immobilizer is worn for the first two weeks except when the patient is performing exercises or is at home and thus safe from injury. In conjunction with the program of rehabilitation for the shoulder, the patient is encouraged to exercise the elbow, wrist, and hand several times a day. At two weeks, the sutures are removed, the use of the sling is discontinued, and the patient is allowed to use the arm progressively for activities of everyday living. If the shoulder is tight at two weeks, the patient is instructed in gentle stretching exercises. When the patient has a functional range of motion, approximately six to eight weeks after the operation, a formal strengthening program is begun. A shoulder-strengthening program for the deltoid, rotator cuff, and scapular stabilizers is initiated only when the patient has regained a functional range of motion. Athletes are not permitted to return to competitive sports activity until they have regained a full functional range of motion and normal muscle strength; this usually occurs after six to ten months.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Operative Technique
 Results
Discussion
 References
 
One hundred and twenty-six patients (128 shoulders) returned for clinical evaluation and were interview by one or two of us (C. A. R., Jr., and M. A. W.), and twelve patients (fourteen shoulders) were examined by their referring physician. Additional information was also obtained from referring physicians, medical records, and radiographs. The patients were evaluated with a standardized evaluation form proposed by the American Shoulder and Elbow Surgeons5, which independently documents pain, range of motion, strength, stability, and function. The patients were also assessed with the grading system of Rowe and Zarins56.

The average duration of follow-up was five years (range, two to twelve years). On the basis of the grading system of Rowe and Zarins56, there were 103 good or excellent results, four fair results, and one poor result in Group I. Of the five shoulders that had a fair or poor result, three had had a previous operation. In Group II, twenty-nine shoulders had a good or excellent result, three had a fair result, and two had a poor result. Four of the shoulders that had a fair or poor result had had a previous operation.

Range of Motion

Group I
For the seventy-six shoulders that had not had a previous operation, the mean postoperative range of motion was 170 degrees (range, 130 to 180 degrees) of elevation, 47 degrees (range, 20 to 60 degrees) of external rotation, and internal rotation to the spinous process of the ninth thoracic vertebra (range, the fourth lumbar to the sixth thoracic vertebra). Compared with the normal shoulder, the affected shoulder lost an average of 5 degrees (range, 0 to 20 degrees) of elevation, 7 degrees (range, 0 to 40 degrees) of external rotation, and two vertebral segments (range, zero to five vertebral segments) of internal rotation.

The thirty-two shoulders that had had at least one previous operation demonstrated a mean postoperative range of motion of 166 degrees (range, 140 to 175 degrees) of elevation, 40 degrees (range, 20 to 50 degrees) of external rotation, and internal rotation to the spinous process of the tenth thoracic vertebra (range, the fourth lumbar to the seventh thoracic vertebra). The affected shoulder lost an average of 8 degrees (range, 0 to 30 degrees) of elevation, 9 degrees (range, 0 to 40 degrees) of external rotation, and one vertebral segment (range, zero to two vertebral segments) of internal rotation.

Group II
For the fourteen shoulders that had not had a previous operation, the mean postoperative range of motion was 176 degrees (range, 160 to 190 degrees) of elevation, 64 degrees (range, 30 to 80 degrees) of external rotation, and internal rotation to the spinous process of the sixth thoracic vertebra (range, the tenth to the fourth thoracic vertebra). Compared with the normal shoulder, the affected shoulder lost an average of 7 degrees (range, 0 to 15 degrees) of elevation, 5 degrees (range, 0 to 20 degrees) of external rotation, and one vertebral segment (range, zero to two vertebral segments) of internal rotation.

For the twenty shoulders that had had at least one previous operation, the mean postoperative range of motion was 163 degrees (range, 150 to 180 degrees) of elevation, 63 degrees (range, 10 to 80 degrees) of external rotation, and internal rotation to the spinous process of the eighth thoracic vertebra (range, the first lumbar to the fifth thoracic vertebra). The affected shoulder lost an average of 9 degrees (range, 5 to 20 degrees) of elevation, 6 degrees (range, 0 to 30 degrees) of external rotation, and one or two vertebral segments of internal rotation.

Stability

Group I
One hundred and five shoulders (97 per cent) (103 patients) demonstrated normal stability, and the patients had a negative apprehension test. These patients also reported normal stability while performing all fifteen activities of daily living included in the function category of the American Shoulder and Elbow Surgeons evaluation form5. One of the three remaining patients (three shoulders) had recurrent anterior subluxation associated with popping and pain three months after the operation. Additional rehabilitation did not markedly decrease the symptoms or disability, and a subsequent reconstruction was performed. The second patient demonstrated mild but persistent apprehension at the five-year follow-up examination, but the disability did not prevent him from participating in collegiate football. The third patient had discomfort, without frank apprehension, when the arm was stressed in a position of abduction and external rotation.

Group II
Thirty-two shoulders (94 per cent) (thirty patients) demonstrated glenohumeral stability on physical examination, and the patients were asymptomatic on apprehension testing. These patients reported normal stability of the shoulder for all activities of daily living5. Two patients (two shoulders) demonstrated apprehension or had recurrent instability. One of them sustained an anterior dislocation of the glenohumeral joint eighteen months after the operation, but the shoulder was successfully rehabilitated. The injury remained an isolated event with no additional episodes of instability by the time of the four-year follow-up examination. The second patient reinjured the shoulder seven months after the operation and had persistent pain and apprehension on provocative stress testing of the arm in a position of abduction and external rotation at the five-year follow-up examination.

Strength
According to the grading system of the American Shoulder and Elbow Surgeons evaluation form5, one hundred and six shoulders (98 per cent) in Group I had good or normal strength postoperatively, compared with thirty shoulders (88 per cent) in Group II.

Function

Group I
Ninety-eight shoulders (91 per cent) functioned normally for all fifteen activities listed on the American Shoulder and Elbow Surgeons evaluation form5. Additionally, according to the criteria of Rowe and Zarins56, no limitations in work or sports activities, including the ability to throw a baseball or football, were noted for these shoulders. Four shoulders had mild limitation with regard to overhead work and sports activities, four had moderate limitation, and two could not be used for overhead work and sports activities because of discomfort or apprehension.

Of the fifty-five patients who had been involved in recreational, high-school, or collegiate athletics, all but five returned to sports activities. Three of these five patients did not participate for reasons unrelated to the shoulder, and two did not participate because of limited motion or because of discomfort during overhead use of the extremity. Of the fifty patients who continued to participate in sports, eight changed sports to decrease the level of participation, thirty-one returned to the same level of participation, and eleven increased the level of participation compared with the preoperative level. Sixteen patients had participated in sports requiring overhead use of the extremity. Of these, five changed the position or sport that they played, six returned to the same level of participation, and five increased the level of participation from high-school to collegiate athletics.

Group II
Twenty-nine shoulders (85 per cent) functioned normally for all fifteen activities of the American Shoulder and Elbow Surgeons evaluation form5, with no limitations in work and sports activities; one had mild limitation with regard to overhead work and sports activities; two had moderate limitation; and two could not be used for overhead work and sports activities.

Of the fifteen patients who had participated in recreational, high-school, or collegiate athletics, two did not return to sports activity for reasons unrelated to the shoulder, four changed the sport or position that they played, six returned to the same level of participation, and three increased their level of participation compared with the preoperative level. Eight patients had participated in sports requiring overhead use of the extremity. Of these, one did not return to sports activities for reasons unrelated to the shoulder, three changed the position or sport that they played, three returned to the same level of participation, and one increased the level of participation.

Pain
Postoperatively, 102 patients (96 per cent) in Group I reported no pain or only slight discomfort after strenuous activity. Of the remaining four patients, three complained of slight but constant discomfort at rest and moderate pain with activity and one had moderate pain at rest that was exacerbated by activity.

Twenty-nine patients (91 per cent) in Group II had slight or no pain with daily, work, and sports activities. Two patients complained of activity-related pain, which they controlled with the intermittent use of non-steroidal anti-inflammatory medication, and three patients had moderate discomfort with most activities, including work and sports.

Analysis of Fair and Poor Results
The result for five shoulders in each group was rated fair or poor, according to the grading system of Rowe and Zarins56. Of these ten shoulders, seven (three from Group I and four from Group II) had had fourteen previous reconstructive procedures. Four of the seven had a fair result and three, a poor result.

One of the seven patients was a thirty-four-year-old man who had had six previous shoulder reconstructions. The operative findings included moderate degenerative changes of the glenoid and a large articular defect in the humeral head secondary to coracoid impingement after a Bristow procedure. At the six-year follow-up examination, the shoulder was stable and demonstrated 140 degrees of forward elevation and 30 degrees of external rotation. However, persistent symptoms associated with radiographic evidence of progressive degenerative joint disease necessitated the use of anti-inflammatory medication as well as vocational rehabilitation.

Another patient was a twenty-four-year-old man who was seen at our institution after a Bristow procedure and a subsequent staple capsulorrhaphy. At the time of the operation, there were mild degenerative changes as well as a marked metallic synovitis secondary to a galvanic reaction from dissimilar loose metallic staples. At the time of the thirty-six-month follow-up, the patient had a negative apprehension test but had discomfort with provocative stress testing. Compared with the non-dominant, contralateral upper extremity, the involved shoulder demonstrated a 20 per cent loss of forward elevation and external rotation. No obvious change in radiographic findings was noted in the follow-up interval, despite the evidence of early degenerative joint disease on the preoperative radiographs.

A third patient who had a fair or poor result as well as previous reconstructive procedures was a twenty-two-year-old man who complained of moderate limitation in overhead work and sports activities six years after the operation. He was dissatisfied with his throwing ability, was unable to serve a tennis ball, and had discomfort in the shoulder with a number of activities. This patient had been seen at our institution with recurrent instability despite two previous reconstructions, which included a primary anterior capsulorrhaphy and a subsequent Bristow procedure. The operative findings at the time of the revision operation included early degenerative changes of the anterior aspect of the glenoid and humeral head, a non-union of the coracoid process, and a loose intra-capsular coracoid fixation screw. Radiographs made at the latest (seven-year) follow-up examination revealed early degenerative changes and progressive narrowing of the glenohumeral joint space.

The group also included a thirty-six-year-old man who had a ten-year history of recurrent instability after a Bristow procedure. At the time of the revision operation, multiple loose bodies were removed and moderate degenerative changes of the glenohumeral joint were noted. The symptoms did not change after the operation even though the shoulder remained stable and there was no progression of radiographic findings compared with the early degenerative changes noted on the preoperative radiographs.

Another patient was a forty-four-year-old woman who had had a Magnuson-Stack procedure when she was seventeen years old. She was seen with moderate glenohumeral osteoarthrosis and posterior glenohumeral subluxation secondary to a 30-degree internal rotation contracture of the shoulder. The patient had a coronal z-plasty lengthening of the subscapularis at the time of the anterior capsular imbrication procedure and did well for approximately four years, after which progressive degenerative changes necessitated a total shoulder arthroplasty.

Also in this group was a twenty-four-year-old man who had had a Magnuson-Stack procedure but continued to have symptomatic instability. He had a revision procedure at our institution. The postoperative course was uneventful until eighteen months after the revision, when the shoulder redislocated. Rehabilitation of the shoulder was successful, and the patient eventually returned to his previous occupation in law enforcement.

The last of the seven patients was initially seen several years after a Putti-Platt procedure. Physical examination at that time demonstrated a 90 per cent loss of external rotation compared with the normal shoulder. Mild degenerative changes of the glenohumeral joint were noted at the time of the capsular reconstruction. At the time of the follow-up examination, at forty-two months, the shoulder was stable but the patient noted discomfort related to both activity and barometric changes. The radiographic findings remained unremarkable.

Three shoulders had a fair result but no previous operative intervention; two were in Group I and one was in Group II. The radiographic findings were normal in two of these shoulders. One shoulder was in a fifteen-year-old boy who played football and who had a fracture of the anterior aspect of the glenoid that involved 25 per cent of the articular surface. At the five-year follow-up examination, the patient had a positive apprehension test and, although he played college football and was able to bench-press 290 pounds (131.5 kilograms), he had mild-to-moderate discomfort. The radiographs revealed early degenerative changes predominantly involving the glenoid. The second shoulder was in a twenty-three-year-old iron worker who had glenohumeral discomfort and popping during rehabilitation of the shoulder twelve weeks after the operation. Return of motion earlier than expected suggested a failed repair, which was confirmed during a subsequent examination with diagnostic arthroscopy performed with the patient under anesthesia. The patient had a revision anterior capsular imbrication procedure, and the result was excellent at the three-year follow-up examination. The third shoulder was in a thirty-three-year-old mechanic. The result was rated as good at seven months after the operation but was rated as fair at the most recent follow-up examination, at four years. The patient had initially returned to digging postholes and weight-lifting but had reinjured the shoulder and had remained symptomatic.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Operative Technique
 Results
 Discussion
References
 
In 1956, Rowe54 classified instability of the shoulder into two groups: traumatic and atraumatic. Of the 500 dislocations of the shoulder that he analyzed from 1934 to 1954, 96 per cent (478) were classified as traumatic in origin and 4 per cent (twenty-two) were atraumatic. Since that time, a number of authors have emphasized the importance of identifying the etiology of the instability through careful recording of a history, thorough physical examination, and radiographic evaluation1,13,39,56,59,63,64. The importance of an accurate diagnosis and subsequent treatment cannot be overemphasized as twenty (47 per cent) of the forty-three shoulders in a study by Cooper and Brems13 had been previously operated on in an attempt to correct instability or to decompress presumed subacromial impingement. Similarly, fifty-two shoulders in the present study had had at least one previous reconstructive procedure, including twenty-two shoulders (15 per cent) that had been previously operated on for an incorrect diagnosis. In order of decreasing frequency, misdiagnoses in the present study included impingement, tear of the rotator cuff, biceps tendinitis, thoracic outlet syndrome, and herniation of a cervical disc. One patient, who had a traumatic subluxation of the shoulder, had been managed previously with resection of a rib for presumed thoracic outlet syndrome and with a subsequent carpal-tunnel release when symptoms persisted after the first operation. Another patient, who had an initial diagnosis of a cervical lesion, had been managed initially with cervical discectomy, two arthrograms, and three subsequent arthroscopic procedures unrelated to capsular repair or reconstruction.

When an operative approach is contemplated for recurrent anterior glenohumeral instability, it is essential to identify any factors that may compromise the operative results, such as large osseous defects of the humeral head, intrinsic capsular injury, a tear of the rotator cuff, fracture of the glenoid rim, or generalized ligamentous laxity. Seventeen (47 per cent) of thirty-six patients in a report by Neer and Foster40, twenty (50 per cent) of forty patients in a study by Altchek et al.1, twenty-nine (76 per cent) of thirty-eight patients in a series of Cooper and Brems13, and fifty-five (40 per cent) of our 138 patients had generalized ligamentous laxity. In these same series, the prevalence of Bankart lesions was quite variable and ranged from 14 to 90 per cent. The disparity among the findings in these reports deserves emphasis as diagnostic studies such as magnetic resonance imaging, computer tomographic arthrography, and arthroscopic examination are usually successful in identifying capsulolabral or Bankart lesions but may fail to reveal the importance of abnormal capsular redundancy. In the absence of capsulolabral abnormality, the diagnosis may be missed and an incorrect operative procedure may be performed.

In 1992, Bigliani et al.6 studied the tensile properties of the inferior glenohumeral ligament and determined that the ligament was subject to substantial plastic deformation before failure or loss of its attachment. In 1993, Speer et al.57 reported the effect of a Bankart lesion on glenohumeral translation in cadaveric shoulders and concluded that the lesion was not solely responsible for the increased anterior translation of the shoulder that was necessary to produce an anterior glenohumeral dislocation. In support of the finding of Bigliani et al., they hypothesized that plastic deformation of the inferior glenohumeral ligament must occur for an anterior dislocation to take place.

Our observations support the conclusions of these studies and suggest that patients with recurrent glenohumeral instability have varying degrees of capsular injury as a result of intrinsic failure of the collagen fibers. This is perhaps best understood by reviewing the fundamentals depicted on a force-deformation curve. Initially, small anteriorly directed forces correspond to a disproportionally large capsular deformation. This is followed by collagen microfailure on the linear portion of the curve as the force on the proximal end of the humerus increases. If the force on the capsular structures is reduced at a point before complete disruption, the capsule will appear grossly intact despite a substantial strain injury causing elongation or stretching of the capsular ligaments. It is this mechanism of injury that may account for recurrent instability of the shoulder despite the absence of a Perthes-Bankart lesion. In patients who have a Perthes-Bankart lesion, the abnormality may be partially explained by a difference in loading rates and the different mechanical properties of the anterior aspect of the glenoid labrum and glenohumeral ligaments. It must be emphasized that patients who have sustained a traumatic injury may have an obvious Perthes-Bankart lesion in addition to a more subtle anteroinferior capsular laxity. Repair of the former with neglect of the latter may contribute to persistent or recurrent instability.

In contrast to a number of previously reported reconstructive procedures for anterior instability of the shoulder7,15-17,23,24,28,34-36,38,43,44,48,58,61, the operation described in the present report is an anatomical method of reconstruction that affords great latitude in the correction of the abnormality encountered at the time of the operation. The anatomical capsular imbrication procedure is a physiological repair, previously described by the senior one of us (C. A. R., Jr.), that directly addresses the source of recurrent glenohumeral instability regardless of its etiology50,51. The procedure includes repair of the capsulolabral injury, when present, and reinforcement of the anteroinferior capsular ligaments by a double-breasting technique that decreases the over-all capsular volume.

This reconstruction is a modification of the Putti-Platt, the Bankart, and the Neer capsular shift procedures, and several points deserve emphasis. First, only the proximal two-thirds of the subscapularis tendon is detached while the distal third of the tendon is maintained intact. This has the theoretical advantage of preserving a portion of the tendon's proprioceptive capability and protecting the anterior humeral circumflex vessels, which are the primary blood supply to the humeral head. The intact portion of the tendon is also gently stripped and retracted from the underlying capsule, allowing visualization of the inferiormost aspect of the capsule while protecting the axillary nerve and vessels. Second, the deltopectoral interval is carefully developed and the cephalic vein is taken laterally with the deltoid as most of the tributaries in this region arise from this muscle. In our experience, preservation of the vein contributes to an easier postoperative course, whereas routine ligation produces venous congestion in the upper extremity and increases postoperative discomfort. Third, it is unnecessary to detach the coracoid process or conjoined tendons in order to gain adequate exposure. Occasionally, we release the proximal centimeter of the pectoralis major tendon to allow better visualization of the inferior aspect of the capsule. This also facilitates identification of the axillary nerve, which passes just inferior to the capsule as it exits the quadrilateral space. Fourth, proper identification of the musculocutaneous and axillary nerves cannot be overemphasized. Identification of the axillary nerve is especially critical so that it can be protected when the inferior aspect of the capsule is opened and repaired. Fifth, the capsule is divided in a vertical fashion midway between its glenoid and humeral site of attachment. This provides excellent intra-articular exposure for a repair of a Perthes-Bankart lesion, is easy to perform, and facilitates subsequent imbrication that reinforces the capsular reconstruction. Sixth, the proximal two-thirds of the subscapularis tendon is repaired anatomically to itself, which helps to minimize the development of undesirable internal rotation contractures of the glenohumeral joint.

In this study, 132 (93 per cent) of the results were rated as good or excellent, with a high degree of patient satisfaction and marked improvement in the ratings for pain, strength, stability, and function5. In accordance with the anatomical concept of the repair set forth in this report, a physiological preservation of motion was noted that compared favorably with that in other series1,13,15,59. The results after a previous reconstructive operation were encouraging, with forty-five (87 per cent) good or excellent results and seven (13 per cent) fair or poor results. Despite this success, revision anterior reconstruction of the shoulder is a formidable challenge with a less predictable outcome; seven of the ten patients for whom the result was fair or poor had had failed previous reconstructive procedures. While progressive symptoms of discomfort were noted in the subset of patients who had had a previous operation and degenerative changes of the glenohumeral joint, there was no relationship between symptomatic instability after the index procedure and the duration of follow-up.

In summary, the merit of any anterior shoulder reconstruction depends on its ability to restore premorbid function and stability while maintaining a physiological range of motion. On the basis of our analysis, we concluded that the anatomical capsular imbrication procedure is an effective means of reconstruction for recurrent anterior instability of the shoulder, regardless of its etiology.

NOTE: The authors thank Kathleen Kelley, without whose dedication this project could not have been completed.


   Footnotes
 
*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.

{dagger}Read at the Annual Meeting of The American Academy of Orthopaedic Surgeons, San Francisco, California, February 19, 1993.

{ddagger}Department of Orthopaedics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7774.

§Department of Orthopaedic Surgery, Kantonsspital, St. Galden 9007, Switzerland.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Operative Technique
 Results
 Discussion
 References
 

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