MULTIDIRECTIONAL INSTABILITY
AND THE
ROTATOR INTERVAL:
TREATMENT OPTIONS
Larry
D. Field, M.D.
Mississippi
Sports Medicine & Orthopaedic Center
Jackson, Mississippi
As
experience has increased in shoulder arthroscopy, improved techniques and
instrumentation have developed to address a number of pathologic conditions.
These improvements have increased the capabilities of the arthroscopist. As a
result, arthroscopic procedures designed to address conditions such as
multidirectional instability have developed.
I. Multi-directional instability
A. Definition of pathologic condition (etiology/pathology)
B. Signs and symptoms
C. Nonoperative treatment
D. Operative treatment options
1. Rotator
interval plication
2. Thermal Capsulorrhaphy
3. Suture capsulorrhaphy
4. Transglenoid capsular shift
5. Capsular tuck procedures
6. Combined procedures
II. Rotator Interval Plication
A. Anatomy
The
rotator interval occupies a triangular space with its apex centered at the
transverse humeral ligament over the biceps sulcus and its greatest width
located at the base of the coracoid process. This interval space is bordered
superiorly by the anterior margin of the supraspinatus tendon and inferiorly by
the superior border of the subscapularis tendon and is usually bridged by
glenohumeral joint capsule. This rotator interval capsule is then structurally
enhanced the CHL and the SGHL as it courses from the anterosuperior labrum deep
to the substance of the rotator interval capsule and the CHL to insert near the
lesser tuberosity.
B. Role of
rotator interval capsule in shoulder stability
1. Basic science
a. Harryman (imbrication decreased humeral head translations)
b. Schwartz (significant role in posterior stability)
2. Clinical studies
a. Rowe (plication supplemented open stabilizations)
b. Field (rotator interval plication used as primary technique for selected cases of multidirectional instability)
3. Rotator interval plication can improve stability and can be used occasionally as a primary stabilization technique, but more commonly as a supplement to other stabilization procedures.
C. Indications
for rotator interval plication
I. Multidirectional instability
a. Open or arthroscopic rotator interval capsule plication for some patients with a degree of multidirectional instability in whom an extensive nonsurgical treatment program has failed and where arthroscopic glenohumeral joint visualization shows no other pathology is present. Patient with high degrees of inferior instability and examinations that show more than a 2+ sulcus sign are not good candidates for isolated rotator interval plication.
2. Supplemental stabilization
Arthroscopic rotator interval plication carried out as a supplement to a primary arthroscopic stabilization procedure such as Bankart repair can be performed. Also, certain cases involving thermally assisted capsulorrhaphy can be likewise supplemented using arthroscopic rotator interval plication techniques.
D. Arthroscopic
rotator interval plication techniques
1. Glenohumeral technique
2. Bursal-sided technique
Initiation
of intra-articular rotator interval repair. Note the suture transport device
through the subscapularis tendon and middle glenohumeral ligament and the
spinal needle through the anterior margin of the supraspinatus tendon and
adjacent capsule. A no. 1 Prolene suture is being advanced through the spinal
needle.
F.
Clinical Results
III. Thermal Capsulorrhaphy
A. Basic science
and clinical application
1. The application of thermal energy to collagen produces a uniform and consistent tissue response.
2. Thermal "shrinkage" of periarticular collagenous soft tissues can reduce capsular volume and assist in the treatment of shoulder instability.
3. In vitro and in vivo studies have clearly demonstrated the measurable and reproducible effects of thermal energy on periarticular collagenous structures.
A lateral plication stitch is seen in place. A second, more medial stitch is being completed as the transporter device retrieves the suture out the anterior portal.
B. Laser assisted
capsular shrinkage procedures (LACS)
I. Indications
2. Surgical technique
C. Radiofrequency
probe thermal capsulorrhaphy
1. Indications
2. Surgical technique
IV. Suture Capsulorrhaphy for Multidirectional Instability
A. Arthroscopic
capsular shift procedure
I. Indications
2. Surgical technique
B. Arthroscopic
capsular tuck procedure
1. Indications
2. Surgical technique
V. Conclusions
A. Arthroscopic techniques designed to address
multidirectional instability are being developed.
B. Early results are encouraging, but additional research is necessary.
C. Indications and surgical technique are important to follow.
REFERENCES
I. Cooper DE, O’Brien SJ, Amoczky SP, et al: The structure and function of the coracohumeral ligament: An anatomic and microscopic study. J Shoulder Elbow Surg 1993;2(2):70-77.
2. Field LD, Savoie FH: Arthroscopic suture repair of superior labral detachment lesions of the shoulder. A J Sports Med 2 1:783-788, 1993.
3. Field LD,
Warren RE, O’Brien SJ, Altchek DW, Wickiewicz TL. Isolated closure of rotator
interval defects for shoulder instability. Am
JSports Med 23: 55 7-563, 1995.
4. Harryman DT,
Sidles JA, Harris SL, et al: The role of the rotator interval capsule in
passive motion and stability of the shoulder. JBone Joint Surg 74A: 53-66, 1992.
5. Jobe C, Miller C, Savoie FH: Diagnosis and management of detachment lesions of the superior and middle glenohumeral ligaments. Arthroscopy. Accepted for publication.
6. Nobuhara K.
Ideda H: Rotator interval lesion. Clin
Orthop 223. 44-50, 1987.
7. O’Brien SJ, Arnoczky SP, Warren RE, et al: Developmental anatomy of the shoulder and anatomy of the glenohumeral joint, in Rockwood DA, Masten FA (eds): The Shoulder. Third edition. Philadelphia, JB Lippincott, 1983.
8. Ovesen J,
Nielsen 5: Experimental distal subluxation in the glenohumeral joint. Arch Orthop Trauma Surg 104: 78-81, 1985.
9. Rowe CR,
Zarins B: Recurrent transient subluxation of the shoulder. J Bone Joint Surg 63A:
863-8 72, 1981.
10. Schwartz E,
Warren RE, O’Brien SJ: Posterior shoulder instability. Orthop Clin North Am 18:409-419, 1987.
11. Snyder SJ. Shoulder arthroscopy. New York: McGraw Hill, 1994.
12. Treacy SH, Savoic FH, Field, FD: Rotator interval capsule closure: an Arthroscopic technique. Arthroscopy 13(1): 103-6, 1997.
13. Warner JJP,
Deng X-H, Warren RE, et al: Static capsuloligamentous restraints to
supenorinferior translation of the glenohumeral joint. Am JSports Med 20: 6 75-685, 1992.