The Open Capsular Shift-Latarjet Procedure for Recurrent Anterior Shoulder Instability

Background: Capsular management is having an increasingly important place during the open Latarjet procedure especially in preventing postoperative glenohumeral arthritis. The open capsular shift-Latarjet procedure consists of the classic Latarjet procedure associated with a glenoid T-based capsular shift to treat patients with high risk of recurrent anterior shoulder instability. Indications: Patients presenting with humeral and/or glenoid bone loss, patients practicing professional activities or sports at risk of recurrence and without any previous capsular surgery, or major capsular deficiency. Technique Description: After a classic deltopectoral approach and the osteotomy of the coracoid process, a horizontal split of the subscapularis is performed. Then a glenoid T-based capsulotomy is performed, and 2 passing wire suture threads are passed through the inferior flap of the capsule to prepare the capsular shift. A first, soft, all-sutured anchor is inserted at the inferior part of the glenoid medially to the articular surface. The coracoid graft is then positioned with a first inferior cancellous screw to be flush with the articular surface and fixed using a second cancellous screw. A second anchor is placed laterally and superiorly to the coracoid at the anterior scapular neck. The capsular shift is performed using a passing wire technique to suture the capsular flap to both anchors and to ensure the extraarticular positioning of the coracoid. Results: Bouju et al found a low rate of recurrence with no revision surgeries and a significative lower incidence of osteoarthritis (8.6%) at 10-year follow-up compared with the current literature when suturing the capsule to the coracoid process. Itoigawa et al concluded that suturing the capsule on the coracoid may increase the risk of osteoarthritis due to a direct contact between the humeral head and the transferred coracoid, thus we suggest attaching the capsule over the glenoid. Discussion/Conclusion: With appropriate patient selection, this technique is safe and reliable to treat patients with anterior instability without any specific risk related to the surgery. The association of the capsular repair is an appropriate solution to better restore the anatomy and to prevent the long-term risk of glenohumeral arthritis.

Biomechanical Comparison of Capsular Repair, Capsular Shift, and Capsular Plication for Hip Capsular Closure: Is a Single Repair Technique Best for All?

Background: In hip arthroscopy, the best capsular closure technique to prevent microinstability in some patients while preventing overconstraints in other patients has yet to be determined. Purpose: To evaluate the biomechanical effects of capsular repair, capsular shift, and combination capsular shift and capsular plication for closure of the hip capsule. Study Design: Controlled laboratory study. Methods: Eight cadaveric hips (4 male and 4 female hips; mean age, 55.7 years) were evaluated in 7 conditions: intact, vented, capsulotomy, side-to-side repair, side-to-side repair with capsular plication (interval closure between iliofemoral and ischiofemoral ligaments), capsular shift repair, and capsular shift repair with plication. Measurements, via a 360° goniometer, included internal and external rotation with 1.5 N·m of torque at 5° of extension and 0°, 30°, 60°, and 90° of flexion. In addition, the degree of maximum extension with 5 N·m of torque and the amount of femoral distraction with 40 N and 80 N of force were obtained. Repeated-measures analysis of variance and Tukey post hoc analyses were used to analyze differences between capsular conditions. Results: At lower hip positions (5° of extension, 0° and 30° of flexion), there was a significant increase in external rotation and total rotation after capsulotomy versus the intact state ( P < .05). At all hip flexion angles, there was a significant increase in external rotation, internal rotation, and total rotation as well as a significant increase in maximum extension after capsulotomy versus capsular shift with plication ( P < .05 for all). At all flexion angles, both capsular closure with side-to-side repair (with or without plication) and capsular shift without capsular plication were able to restore rotation, with no significant differences compared with the intact capsule ( P > .05). Among repair constructs, there were significant differences in range of motion between side-to-side repair and combined capsular shift with plication ( P < .05). Conclusion: At all positions, significantly increased rotational motion was seen after capsulotomy. Capsular closure was able to restore rotation similar to an intact capsule. Combined capsular shift and plication may provide more restrained rotation for conditions of hip microinstability but may overconstrain hips without laxity. Clinical Relevance: More advanced closure techniques or a combination of techniques may be needed for patients with hip laxity and microinstability. At the same time, simple repair may suffice for patients without these conditions.

Failure Rates in Contact versus Non-Contact Athletes Following Arthroscopic Inferior Capsular Shift at 10-Year Follow-Up (237)

Objectives: Arthroscopic Bankart repair has become the surgical procedure of choice for many in the United States, over the Latarjet in Europe, for first time anterior shoulder instability with minimal bone loss, less than 20%. However, high recurrence rates in contact athletes have led many to proceed with open type procedures. Our purpose was to compare failure rates and functional outcomes of the arthroscopic inferior capsular shift in contact and non-contact athletes. We hypothesized that contact and non-contact athletes would exhibit excellent functional outcomes and return to sport with low recurrence rates. Methods: A consecutive series of 69 shoulders in 61 contact and non-contact athletes underwent an arthroscopic inferior capsular shift with ≥3 suture anchors by a single surgeon (1999-2018). Thirty shoulders in 26 contact athletes (6 women; 25.3±8.1 years) and 39 shoulders in 35 non-contact athletes (7 women; 34.8±10.0 years) were included. Inclusion criteria were complete anterior inferior labral detachment (6 unit hours) and ≥2-year follow-up. Exclusion criteria included multidirectional instability, engaging Hill Sachs lesion or glenoid bone loss >30%. A modified 3-portal technique utilizing the outside-in method was employed. A conservative rehabilitation program was followed with return to sport no sooner than 3 months in non-contact, 4-5 months in contact, and 9 months in throwing athletes. Functional outcomes were measured using Constant Scores, American Shoulder and Elbow Surgeons (ASES) Score, Western Ontario Shoulder Instability Index (WOSI), Melbourne Instability Shoulder Scale (MISS), and Rowe. Forward elevation, external rotation at side and 90° abduction and internal rotation range of motion (ROM) were measured. Independent samples t-tests were used to assess differences in outcomes between contact and non-contact athletes (Bonferroni correction: p<0.006). Results: Follow-up was 11.0±3.5 years (range 2-16 years) in contact athletes and 12.2±4.3 years (range 2-21 years) in non-contact athletes (p=0.264). Contact athletes were significantly younger than non-contact athletes (p<0.0001). An average of 3.9±1.7 and 3.1±1.0 suture anchors were used in contact and non-contact groups, respectively (p=0.348). There were no significant differences in post-operative functional scores (all p>0.053) or shoulder ROM (all p>0.034) between groups. Forward flexion was 163.75±16.8° pre-operatively and 168.89±13.0° post-operatively in contact athletes (p=0.212) and 162.5±13.7° preoperatively and 170±7.7° post-operatively in non-contact athletes (p=0.005). External rotation at the side was 59.04±19.4° pre-operatively and 67.9±18.6° value post-operatively in contact athletes (p=0.094) and 52.94±25.1° pre-operatively and 62.83±14.3° post-operatively in non-contact athletes (p=0.062). External rotation at 90° abduction was 92.61±20.1° pre-operatively and 93.39±12.9° post-operatively in contact athletes (p=0.867) and 88.33±21.1° pre-operatively and 87.5±8.1° post-operatively in non-contact athletes (p=0.842).Internal rotation behind the back was to an average of T11 pre-operatively and T9 post-operatively in contact athletes (p=0.004) and L1 pre-operatively and T9 post-operatively in non-contact athletes (p=0.001).In contact and non-contact athletes, respectively, Rowe scores were 65.35±17.6 and 51.25±13.2 preoperatively and 89.22±17.6 and 96.25±12.4 post-operatively (p=0.002 and p<0.001); Constant Scores were 75.69±12.6 and 61.67±11.3 pre-operatively 85.79±19.6 and 89.71±13.6 post-operatively; ASES scores were 80.40±15.3 and 62.14±22.2 pre-operatively and 93.91±9.9 and 86.06±20.7 post-operatively (p<0.001 and p<0.001); MISS scores were 59.36±12.4 and 48.39±15.5 preoperatively and 88.20±13.5 and 75.75±19.7 post-operatively (p<0.001 and p<0.001); WOSI was 3.50±1.3 and 4.55±1.4 pre-operatively and 1.70±3.0 and 2.94±2.7 post-operatively (p=0.101 and p=0.066). Overall recurrence rate was 4.3% (3/69). Two contact athletes (2/30; 6.7%) and one non-contact athlete (1/39; 2.6%) experienced a traumatic recurrent instability event requiring revision surgery (p=0.439). These three patients underwent a revision arthroscopic inferior capsular shift with an additional 3-4 plication sutures and returned to pre-injury sports including hockey, football, skiing, and tennis without recurrence of instability at greater than 7 years following the revision surgery. Conclusions: Modified arthroscopic inferior capsular shift utilizing ≥3 suture anchors with plication sutures returns contact and non-contact athletes to sports with excellent functional outcomes, low recurrence rates (3/69), and full unrestricted ROM. While loss of ROM is a concern, particularly in overhead athletes, ROM was successfully restored in all patients, most notably in external rotation at 90° abduction. We recommend a modified arthroscopic inferior capsular shift with plication sutures as the primary procedure in all athletes with anterior instability with less than 30% bone loss excluding those with high Beighton scores rather than a Latarjet.

Arthroscopic remplissage: a valuable adjunct to arthroscopic Bankart’s repair in shoulder instability

<p class="abstract">Current study present results of arthroscopic shoulder stabilisation surgery. 46 consecutive patients with recurrent anterior shoulder dislocations and less than 25% Glenoid bone loss were treated with arthroscopic surgery in 2017-2020. Arthroscopic repair of Bankart’s lesion with capsular shift was performed in each. In 8 patients, where the Hill sach’s lesion was “off track” or “engaging”, arthroscopic remplissage was performed along with arthroscopic Bankart’s repair. There was no recurrence of shoulder instability after a mean follow up of 1 year. This included the non-engaging Hill sach’s group (treated with Bankart’s repair) as well as the engaging or off track Hill sach’s group (treated with Bankart’s repair and remplissage). All patients went on to obtain full forward flexion, full abduction and internal rotation. The Bankart’s and remplissage group had a mean of 8 degrees restriction of external rotation. SST scores and oxford scores had improved considerably on follow up in both groups Arthroscopic shoulder surgery provides a safe and reliable option in the management of recurrent shoulder dislocations. Arthroscopic remplissage is a useful adjunct to Bankart’s repair when treating the difficult problem of a large engaging Hill Sachs lesion.</p><p class="abstract"> </p>