Multidirectional glenohumeral instability is amenable to arthroscopic pancapsular capsulorrhaphy

Cases with traumatic onset had higher mean postoperative ASES, satisfaction scores when compared with those with atraumatic onset.

Issue: March 2017

Patients with multidirectional instability of the shoulder experienced an effective and safe treatment with arthroscopic pancapsular capsulorrhaphy with suture anchors at middle-term follow-up in a cohort study.

In the study, multidirectional instability (MDI) was defined clinically as symptomatic instability in more than one direction, one of which was inferior. Surprisingly to the investigators, about 64% of the patients studied had labral detachments and these were also seen in patients with the more classic atraumatic onset of multidirectional glenohumeral instability, according to the findings.

“The most important finding is that arthroscopic pancapsular capsulorrhaphy [APC] can be effective for treating these patients with these complex instability patterns of the shoulder,” Peter J. Millett, MD, MSc, of the Steadman Clinic in Vail, Colo., told Orthopedics Today.

Peter J. Millett, MD, MSc — Peter J. Millett

Arthroscopic capsulorrhaphy

Millett and his colleagues prospectively collected and retrospectively reviewed data on 41 patients with MDI who underwent APC between October 2006 and January 2013. The data included the type of onset of MDI, the intraoperative pathoanatomic findings, the level of sports participation and patient satisfaction, as well as the patients’ American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, Quick DASH and SF-12 physical component summary scores. Researchers also collected information regarding shoulder instability and return to sport and performed a Kaplan-Meier survivorship analysis.

The left shoulder of a patient undergoing panlabral repair with capsular shift with a knotless anchor is shown. View from the anterior portal, the repair of the posterosuperior labrum is visualized as the posterosuperior anchor is placed in the 1 o’clock position is shown (a). View from the anterior portal of the completed posterior labral repair is shown (b). View from the posterior portal of the completed anterior labral repair is shown (c). View from the posterior portal of the completed anterior labral repair is shown (d).

Overall, Millett and colleagues found the patients in this cohort had atraumatic onset of MDI in 22 shoulders and traumatic onset in 23 shoulders. Contrary to conventional thinking, labral detachments were found in 64.4% of patients at the time of surgery. Overall, 38 of 41 patients did not have further surgery; 16.7% of patients reported instability episodes postoperatively; and three patients later underwent revision surgery.

Subjective outcomes improved

Researchers noted all subjective outcome scores significantly improved from their preoperative levels. The mean postoperative ASES score was 92, and 76.7% of patients returned to sports participation at levels equal to or slightly below their preinjury levels. Results of the Kaplan-Meier analysis showed an 87% survivorship at 3 years.

Compared with women, the traumatic onset of instability was 2.3-times more likely to occur in men and the results showed men were also 2.1-times more likely to have concomitant pathoanatomic lesions. Researchers also found men had a higher mean postoperative ASES score. An additional rotator interval closure procedure was 6.9-times more likely to be performed in women than men, perhaps suggesting greater laxity noted at the time of surgery, according to Millett. In addition, women were also about twice as likely as men to experience postoperative subluxations, researchers noted.

Furthermore, study results showed individuals who had a traumatic onset of their MDI had higher mean postoperative ASES and median satisfaction scores, as well as higher return-to-sport rates.

Arthroscopic vs open surgery

Millett noted an advantage of arthroscopic surgery to treat MDI compared with open surgery is surgeons can address the entire shoulder — anterior, posterior, inferior and rotator interval, as well as any labral pathology — in one surgery. In the future, larger cohorts of patients with longer-term follow-up will help develop predictive models to better stratify treatment, Millett said.

“The next step is to do additional longer-term follow-up to see how [patients] do over time and to see what the recurrence rate is. Also, to get bigger cohorts of patients so we can develop predictive models so we can figure out which patients will do best and which patients might need additional procedures to help stabilize their shoulder.” Millett said. – by Casey Tingle

Reference:
Raynor MB, et al. Am J Sports Med. 2016;doi:10.1177/0363546516659644.

For more information:
Peter J. Millett, MD, MSc, can be reached at Steadman Philippon Research Institute, 181 West Meadow Dr., Suite 1000, Vail, CO 81657; email: drmillett@thesteadmanclinic.com.

Disclosure: Millett reports he is a consultant for Arthrex and a reviewer for American Journal of Sports Medicine.