The American Journal of Sports Medicine http://ajs.sagepub.com/ Arthroscopic Treatment of Multidirectional Shoulder Instability in Athletes : A Retrospective Analysis of 2- to 5-Year Clinical Outcomes Champ L. Baker III, Randy Mascarenhas, Alex J. Kline, Anikar Chhabra, Mathew W. Pombo and James P. Bradley Am J Sports Med 2009 37: 1712 originally published online July 15, 2009 DOI: 10.1177/0363546509335464 The online version of this article can be found at: http://ajs.sagepub.com/content/37/9/1712 Published by: http://www.sagepublications.com On behalf of: American Orthopaedic Society for Sports Medicine Additional services and information for The American Journal of Sports Medicine can be found at: Email Alerts: http://ajs.sagepub.com/cgi/alerts Subscriptions: http://ajs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Downloaded from ajs.sagepub.com at UNIV OF DELAWARE LIB on November 29, 2010 Arthroscopic Treatment of Multidirectional Shoulder Instability in Athletes A Retrospective Analysis of 2- to 5-Year Clinical Outcomes Champ L. Baker III,* MD, Randy Mascarenhas,† MD, Alex J. Kline,‡ MD, § ||¶ # Anikar Chhabra, MD, Mathew W. Pombo, MD, and James P. Bradley, MD † From *The Hughston Clinic, Columbus, Georgia, the University of Manitoba Section ‡ of Orthopaedic Surgery, Health Sciences Centre, Winnipeg, Manitoba, Canada, the University of Pittsburgh Medical Center, Department of Orthopaedic Surgery, Pittsburgh, Pennsylvania, § Canyon Orthopaedic Surgeons, Phoenix, Arizona, the ¶Sports Medicine & Orthopaedic # Institute, Duluth, Georgia, and Burke and Bradley Orthopaedics, Pittsburgh, Pennsylvania Background: There are few reports in the literature detailing the arthroscopic treatment of multidirectional instability of the shoulder. Hypothesis: Arthroscopic management of symptomatic multidirectional instability in an athletic population can successfully return athletes to sports with a high rate of success as determined by patient-reported outcome measures. Study Design: Case series; Level of evidence, 4. Methods: Forty patients (43 shoulders) with multidirectional instability of the shoulder were treated via arthroscopic means and were evaluated at a mean of 33.5 months postoperatively. The mean patient age was 19.1 years (range, 14-39). There were 24 male patients and 16 female patients. Patients were evaluated with the American Shoulder and Elbow Surgeons and Western Ontario Shoulder Instability scoring systems. Stability, strength, and range of motion were also evaluated with patient-reported scales. Results: The mean American Shoulder and Elbow Surgeons score postoperatively was 91.4 of 100 (range, 59.9-100). The mean Western Ontario Shoulder Instability postoperative percentage score was 91.1 of 100 (range, 72.9-100). Ninety-one percent of patients had full or satisfactory range of motion, 98% had normal or slightly decreased strength, and 86% were able to return to their sport with little or no limitation. Conclusion: Arthroscopic methods can provide an effective treatment for symptomatic multidirectional instability in an athletic population. Keywords: multidirectional instability; shoulder; arthroscopic; athletes The landmark article by Neer and Foster20 initially outlined the difficulties in the diagnosis and treatment of multidirectional shoulder instability (MDI) and proposed an inferior capsular shift to treat the excessive capsular redundancy that tends to plague patients with MDI of the shoulder. Historically, open capsular shift techniques have been the standard in the operative treatment of patients with MDI. More recently, however, a number of arthroscopic techniques have been described for treatment of MDI. These techniques include thermal or radiofrequency capsulorrhaphy, as well as other arthroscopic approaches using suture techniques and/or suture anchors. Although these techniques show initial promise, many of the reports detailing outcomes after arthroscopic management have included small patient populations and relatively short follow-up periods. We report on the outcomes of 40 symptomatic athletes with shoulder MDI who underwent arthroscopic reconstruction after failure of nonoperative management. || Address correspondence to Mathew W. Pombo, MD, Sports Medicine & Orthopaedic Institute, 3855 Pleasant Hill Road, Suite 470, Duluth, GA 30096 (e-mail: matpombo7@hotmail.com). Presented at the 32nd annual meeting of the AOSSM, Hershey, Pennsylvania, June 2006. No potential conflict of interest declared. The American Journal of Sports Medicine, Vol. 37, No. 9 DOI: 10.1177/0363546509335464 © 2009 The Author(s) 1712 Downloaded from ajs.sagepub.com at UNIV OF DELAWARE LIB on November 29, 2010 Multidirectional Shoulder Instability Treatment 1713 Vol. 37, No. 9, 2009 MATERIALS AND METHODS A retrospective review was performed of 42 consecutive athletes (45 shoulders) who underwent arthroscopic treatment of symptomatic MDI by the senior author (JPB) between August 2002 and May 2005. The criteria used for inclusion in the study group were athletes of any level with minimum 2-year follow-up and the presence of MDI. Patients who displayed unidirectional anterior or posterior instability and those with habitual or psychogenic voluntary shoulder subluxation were excluded from the study. No patients were treated with thermal capsular shrinkage. Two patients (2 shoulders) were lost to follow-up, leaving a final study group of 40 athletes (43 shoulders). The authors have defined MDI of the shoulder as symptomatic instability in more than one direction based on a combination of findings from the patient’s history, physical examination, evaluation under anesthesia, and pathologic findings at arthroscopy. A challenge faced by the authors was the ability to reproducibly define MDI in athletes. The definition in the literature has inconsistently been defined as instability in 2 directions1,2,7,9,16,21 or in 3 directions.16,19,20,22 The definition of MDI originally described by Neer and Foster20 included only patients with uncontrollable, involuntary inferior subluxation or dislocation associated with both anterior and posterior dislocations/subluxations of the shoulder. We chose a more inclusive definition for MDI, similar to definitions provided by McIntyre et al,17 Gartsman et al,8 and McFarland et al.16 Multi-directional instability was defined for this study as inferior instability with at least one other direction (anterior or posterior) of instability. In our practice these patients have been approached and treated similarly to classically defined MDI patients. Patient data were collected retrospectively through review of office charts, operative reports and photographs, and telephone conversations with all patients at latest follow-up. Patient demographics included the following: age, gender, sport, level of competition, dominant versus nondominant arm, traumatic versus atraumatic injury, time to surgery after the injury, and length of follow-up. At final follow-up, patient progress was evaluated using the accepted American Shoulder and Elbow Surgeons (ASES) shoulder index23 (0-100), combining a subjective functional scale and a subjective pain scale. The Western Ontario Shoulder Instability (WOSI) index, a validated disease-specific quality of life measurement tool for patients with shoulder instability,12 was also used as an outcome measure. It consists of 21 questions relating to physical symptoms, sports/work/ recreation, lifestyle, and emotions. Each question is answered on a 100-point scale, with 0 being normal and 100 being the worst score. Therefore, the WOSI index has a worst possible score of 2100. The WOSI percentage score is calculated by subtracting the total score from 2100, and then dividing the result by 2100. Because the ASES scale does not measure stability, we also added a subjective stability scale (0-10, with 0 being completely stable and 10 being completely unstable) at follow-up. A subjective strength scale (0-3, with 3 being normal strength) and a subjective range of motion (ROM) scale (0-3, with 3 being full motion) were used at final follow-up Figure 1. An axial cut of a T2-weighted MRI arthrogram of a right shoulder demonstrating a large capsular volume. as well. Findings at the time of surgery and surgical procedures performed were also noted, along with the aforementioned outcome measures. Operative Treatment Patients who met our inclusion criteria and who had failed nonoperative management were selected for arthroscopic reconstruction. All surgeries were performed by the senior author (JPB). The degree and type of reconstructive procedure performed were based on the findings of the preoperative workup, examination under anesthesia (EUA), and the intraoperative findings at the time of arthroscopy (Figures 1 and 2). Before the arthroscopic procedure was started, all patients underwent a thorough EUA and comparison with the contralateral shoulder. Special attention was given to examining for anterior, posterior, and inferior shoulder laxity. Glenohumeral translation was graded according to the criteria of Altchek et al.1 Inferior laxity was also assessed and determined to be positive if there was a grade 2+ sulcus sign on examination that failed to tighten with external rotation of the shoulder. This information was correlated with preoperative MRI findings, preoperative symptoms of instability, and surgical findings of patulous capsule, inferior glenohumeral ligament injuries, labral injuries, and widened rotator intervals. The surgery was performed under interscalene block alone or general endotracheal anesthesia with interscalene block for perioperative pain control. The patient was positioned in the standard lateral decubitus position. The shoulder was placed in 45° of abduction and 20° of forward flexion. A posterior portal was created slightly inferior and lateral to the standard posterior portal, followed by the establishment of an anterior portal. Downloaded from ajs.sagepub.com at UNIV OF DELAWARE LIB on November 29, 2010 1714 Baker et al The American Journal of Sports Medicine Figure 2. A view from the posterior portal of the anterior labrum before suture capsulolabral plication. The anterior portal was placed high in the rotator interval, from an inside-to-outside fashion via a switching stick. A diagnostic arthroscopy was performed, systematically evaluating the labrum, capsule, biceps tendon, subscapularis, rotator interval, rotator cuff, and articular surfaces with the arm in and out of traction. The posterior shoulder was evaluated with the arthroscope in the anterior portal, looking specifically for a patulous posterior capsule, capsular tears, labral fraying, and posterior labral tears. The type of capsulolabral reconstruction/shift was selected based on patient expectations, preoperative clinical examination, EUA, and pathologic findings at diagnostic arthroscopy. Anterior-inferior and anterior instabilities were always addressed first, followed by a superior labrum, anterior and posterior repair if necessary. Posterior-inferior and posterior instabilities were then addressed and followed by a repeat EUA. If residual inferior laxity remained, the rotator interval was closed. Patients with a patulous capsule without a discrete labral tear received a capsulolabral plication with or without suture anchors. Those with labral tears received a capsulolabral plication with suture anchors. After the capsulolabral repair, the capsule was evaluated for residual laxity and additional plication sutures were placed if necessary. Anterior Instability The anterior capsule/labrum was evaluated with the arthroscope in the posterior portal and the anterior portal was used for instrumentation. The capsule was abraded with an arthroscopic rasp or motorized synovial shaver with special care taken to avoid capsular penetration. In the absence of a labral tear, a 45° suture passer was used to plicate the capsule 1 cm off the labrum at the 5:30-o’clock position on the glenoid and then advanced superomedially to the 4:30-o’clock position on the glenoid. This effectively advanced the inferior capsule (Figure 3). A total of 4 nonabsorbable capsular plication sutures were placed up the face of the glenoid with No. 0 PDS suture (Ethicon, Somerville, New Jersey). This composed a capsulolabral repair without Figure 3. A final view of the anterior suture capsulolabral plication. Figure 4. A view from the anterior portal of the same patient demonstrating the posterior capsulolabral repair. anchors and was used in cases of anterior-inferior capsular laxity even though the labrum was not detached. The degree of tightening was tailored to the amount of capsular laxity encountered intraoperatively. Arthroscopic sutures were tied using an arthroscopic Westin knot. When the anterior/anterior-inferior labrum was found to be completely or partially detached, suture anchors were used to perform the repair/shift. Suture anchors were also used if the labrum was either absent or deficient to restore a buttress with the capsular shift. We used 3.0-mm BioFASTak or Bio-Suture Tak suture anchors (Arthrex Inc, Naples, Florida). The number of suture anchors used was based on the size of the labral tear (minimum, 3). Posterior Instability The arthroscope was placed in the anterior portal and the instruments were placed in the posterior portal. A similar approach to that performed for anterior-inferior instability Downloaded from ajs.sagepub.com at UNIV OF DELAWARE LIB on November 29, 2010 Multidirectional Shoulder Instability Treatment 1715 Vol. 37, No. 9, 2009 was employed for posterior-inferior instability patterns. If no labral injury was noted, a posterior-inferior capsular plication and shift were performed without anchors beginning at the 6:30-o’clock position on the posterior-inferior labrum. A total of 4 nonabsorbable capsular plication sutures were placed by advancing up the glenoid similarly to the anterior-inferior procedure, with the degree of tightening tailored to the amount of capsular laxity encountered intraoperatively. When the posterior labrum was found to be completely or partially detached, suture anchors were used to perform the repair (Figure 4). Once the capsulolabral repair was completed, posterior capsular laxity was again reassessed. Patients with continued capsular laxity subsequently underwent further capsulorrhaphies with sutures placed in the capsule in the intervals between the suture anchors. Rotator Interval Closure Following the reconstructions previously described, an EUA was performed to assess for residual inferior laxity via testing of the sulcus sign and evaluation of the capsule arthroscopically. If present, the rotator interval was closed arthroscopically with the arm position remaining unchanged. The anterior cannula was withdrawn until just outside the capsule. Approximately 1 cm lateral to the glenoid, a crescent suture passer was used to pierce the capsule and a No. 0 PDS suture was passed into the joint. Based on the amount of residual inferior laxity, the rotator interval was closed to further restore inferior stability using a 22° BirdBeak suture passer (Arthrex Inc) to pierce the capsule at a distance from the prior capsular stitch and retrieve the PDS suture. An arthroscopic Westin knot was then tied to complete the rotator interval closure. TABLE 1 Summary of Patient Demographics (Total 43 Shoulders) Gender: men, 25; women, 18 Mean age: 19.09 ± 5.3 years (range, 14-39) Average follow-up: 33.5 ± 8.7 months (range, 24-65) Level of participation: high school, 22 (51%); college, 11 (26%); recreational, 10 (23%) Arm: dominant, 23; nondominant, 20 Origin of injury: traumatic, 22; atraumatic, 21 TABLE 2 Primary Sports at the Time of Injury (Total 43 Shoulders) Sport No. Football Basketball Softball/baseball Swimming Golf Wrestling Cheerleading Volleyball Dancing Martial arts Gymnastics Hockey 10 6 6 4 4 3 3 2 2 1 1 1 strength, and endurance comparable with that of the contralateral side before return to competition. Depending on the sport, most athletes were allowed to return to competition at or around 6 months postoperatively. Postoperative Rehabilitation Immediately after surgery, the rehabilitation protocol employed the use of an UltraSling (DonJoy, Carlsbad, California) that immobilized the shoulder in approximately 30° of abduction and protected the shoulder joint. Cryotherapy was used initially for edema control. On the first postoperative day, the patient began active wrist and elbow flexion and extension exercises as well as gentle pendulums and passive scaption exercises. Patients were immobilized for 4 to 6 weeks depending on the amount of postoperative stiffness seen at follow-up. If the shoulder was developing stiffness, formal physical therapy was begun at 4 weeks. After sling immobilization was discontinued, gentle passive ROM exercises were advanced and active-assisted ROM exercises as well as isometric internal and external rotation exercises were initiated. Range of motion was progressed to full passive and active ROM by 2 to 3 months postoperatively. At this time, capsular stretching exercises were started and isotonic strengthening continued, with emphasis on the rotator cuff. At 4 months postoperatively, patients were progressed into the functional phase of rehabilitation with plyometrics, more aggressive strengthening, and overhead lifting as tolerated. In general, athletes had to achieve painless ROM, RESULTS Patient Demographics Complete demographics are shown in Table 1. There were 24 men and 16 women with an average age at surgery of 19.1 years (range, 14-39). The mean follow-up was 33.5 months (range, 24-65). The dominant shoulder was noted to be involved in 23 (53%) of the cases. All patients were athletes who competed at either the high school, collegiate, or organized recreational level. There were 21 patients (22 shoulders) who competed at a high school level, 10 collegiate athletes (11 shoulders), and 9 patients (10 shoulders) involved in organized recreational sports. The most common sports in the patient population included football (10), basketball (6), softball/baseball (6), swimming (4), and golf (4). A complete list of sports is shown in Table 2. Four patients had undergone a total of 4 previous operations including 3 arthroscopic thermal capsulorrhaphy procedures and 1 open anterior capsulorrhaphy. Twenty-one patients (22 shoulders) described the onset of their shoulder difficulties as resulting from a traumatic injury. Although many patients described having a dislocation as Downloaded from ajs.sagepub.com at UNIV OF DELAWARE LIB on November 29, 2010 1716 Baker et al The American Journal of Sports Medicine their initial injury, only 7 of these were confirmed radiographically or by emergency department records. Of the 21 patients who described a traumatic origin, the average time from injury to surgery was 7.6 months (range, 1-41). Nineteen patients (21 shoulders) could not recall a traumatic injury to their shoulder and were classified as atraumatic. Surgical Findings All of the 43 shoulders (100%) had a redundant inferior capsule. Overall, 16 shoulders (37%) had capsular redundancy anteriorly, posteriorly, and inferiorly. The remainder of shoulders demonstrated a spectrum of injury patterns and pathologic abnormalities. Anteriorly, there were a total of 23 Bankart lesions present in 54% of the shoulders. Of these lesions, 4 were associated with concurrent anterior capsular redundancy and 19 were the only anterior injury noted. Twenty shoulders (47%) had anterior capsular redundancy only. Therefore, 24 shoulders (56%) had a redundant anterior capsule regardless of labral injury. Posteriorly, 23 shoulders (53%) had a patulous posterior capsule only, 3 shoulders (7%) demonstrated posterior capsular redundancy and incomplete labral stripping, 3 shoulders (7%) were noted to have a posterior labral detachment in addition to the capsular lesion, 9 shoulders (21%) had a reverse Bankart lesion only, and 5 (12%) demonstrated incomplete labral stripping only. Therefore, 29 shoulders (67%) had a patulous posterior capsule regardless of labral injury. In the group of 22 shoulders with a traumatic onset of symptomatic instability, 15 shoulders demonstrated anterior labral detachment, 5 shoulders had anterior capsular redundancy, and 2 shoulders had anterior capsular redundancy and labral injury. Posteriorly, 7 shoulders had labral detachment, 3 shoulders had labral stripping, 9 shoulders had capsular redundancy, and 3 shoulders demonstrated capsular redundancy and labral lesions. In the group of 21 shoulders with an atraumatic onset of symptomatic instability, 4 shoulders demonstrated anterior labral detachment, 15 shoulders had anterior capsular redundancy, and 2 shoulders had anterior capsular redundancy and labral lesions. Posteriorly, 2 shoulders had labral detachment, 2 shoulders had labral stripping, 14 shoulders had capsular redundancy, and 3 shoulders demonstrated capsular redundancy and labral stripping. Three patients were noted to have a type 2 superior labrum, anterior and posterior tear that was repaired concurrently. There were no associated full-thickness rotator cuff tears or subacromial space abnormalities. Surgical Procedures Patients with a patulous capsule without a discrete labral tear received a capsulolabral plication with or without suture anchors. Those with labral tears or a deficient labrum received a capsulolabral plication with suture anchors. After the capsulolabral repair the capsule was evaluated for residual laxity and additional plication sutures were placed if necessary. Treatment was individualized to each patient and was based on symptoms in the clinic as well as the EUA and arthroscopic findings. Anteriorly, 22 shoulders (51%) had a capsulorrhaphy performed with anchors, 16 shoulders (37%) had a capsulorrhaphy performed without anchors, and 5 shoulders (12%) had a capsulorrhaphy performed with anchors and additional plication sutures. Posteriorly, 21 shoulders (49%) had a capsulorrhaphy performed with anchors, 13 shoulders (30%) had a capsulorrhaphy performed without anchors, and 9 shoulders (21%) had a capsulorrhaphy performed with anchors and additional plication sutures. The rotator interval was closed in 10 shoulders (23%). In the group of 16 shoulders that had isolated capsular redundancy anteriorly, posteriorly, and inferiorly, capsulorrhaphy with suture alone was performed in 9 patients. Three shoulders had an anterior and posterior capsulorrhaphy performed with anchors only and 2 shoulders had an anterior suture capsulorrhaphy and a posterior capsulorrhaphy performed with anchors. One shoulder had an anterior repair with suture only and a posterior repair with anchors and additional plication sutures, and the remaining shoulder had an anterior repair with anchors and additional plication sutures and a posterior repair with suture only. In these 16 shoulders with isolated capsular redundancy, the rotator interval was closed in 6 shoulders (38%). In one patient a subacromial bursectomy was performed for visualization of the bursal side of the rotator cuff that failed to demonstrate a full-thickness tear. No patient required repair of a partial-thickness rotator cuff tear. Stability At the time of latest follow-up using a subjective stability scale (0-10, with 10 being completely unstable), the mean stability score for the 43 shoulders was 1.8 (range, 0-7). At the time of latest follow-up, using this subjective stability scale, 32 shoulders (74%) scored excellent (0-2); 8 (19%), good (3-4); 1 (2%), satisfactory (5-6); and 2 (5%), poor (≥7). Forty shoulders (93%) thus had excellent or good stability at the time of latest follow-up. Similar results were found in the traumatic and atraumatic subgroups (Table 3). Pain Using a subjective pain scale (0-10, with 10 being the worst pain), the mean postoperative pain score for the 43 shoulders was 1.12 (range, 0-5). For the 22 traumatic shoulders, the mean pain score was 1.20 (range, 0-5) and for the 21 atraumatic shoulders the mean pain score was 1.02 (range, 0-5) (Table 3). Function Using a functional scale based on the ASES system (0-30, with 0 being the worst function), the mean postoperative functional score for the 43 shoulders was 27.5 (range, 21-30). The mean postoperative functional scores for the traumatic and atraumatic cohorts were 28.32 (range, 21-30) and 26.62 (range, 21-30), respectively (Table 3). Downloaded from ajs.sagepub.com at UNIV OF DELAWARE LIB on November 29, 2010 Multidirectional Shoulder Instability Treatment 1717 Vol. 37, No. 9, 2009 TABLE 3 Summary of Patient Results (Total 43 Shoulders) at Latest Follow-upa Outcome Measure All Patients Traumatic ASES (0-100, 0 being worst) WOSI (0-100, 0 being worst) Stability (0-10, 0 being most stable) Pain (0-10, 0 being no pain) Function (0-30, 0 being worst) Range of motion (0-3, 3 being full motion) Strength (0-3, 3 being full strength) 91.37 ± 8.98 (59.86-100) 91.09 ± 9.28 (72.9-100) 1.81 ± 2.06 (0-7) 1.12 ± 1.24 (0-5) 27.49 ± 2.60 (21-30) 2.40 ± 0.66 (1-3) 2.63 ± 0.53 (1-3) 91.09 ± 8.83 (59.86-100) 93.72 ± 10.29 (72.9-100) 1.89 ± 2.32 (0-6) 1.20 ± 1.23 (0-5) 28.32 ± 2.48 (21-30) 2.55 ± 0.67 (1-3) 2.64 ± 0.58 (1-3) Atraumatic 88.85 ± 8.31 (59.86-100) 89.32 ± 8.70 (74.5-98.6) 1.74 ± 1.85 (0-7) 1.02 ± 1.20 (0-5) 26.62 ± 2.56 (21-30) 2.14 ± 0.57 (1-3) 2.57 ± 0.51 (2-3) a All values are listed as the mean results with the corresponding standard deviations. The range of results follows in parentheses. ASES, the American Shoulder and Elbow Surgeons standardized shoulder assessment score; WOSI, the University of Western Ontario Shoulder Instability Index percentage score. All 40 patients stated they were able to return to normal activities of daily living. No patient returned to restricted activities of daily living. Range of Motion Using a subjective ROM scale (0-3: 0 = poor, 1 = limited, 2 = satisfactory, 3 = full), at the time of latest follow-up, the mean ROM score for the 43 shoulders was 2.4 (range, 1-3). Nineteen shoulders (44%) had full ROM and 20 shoulders (47%) had satisfactory ROM. Therefore, 39 shoulders (91%) had satisfactory or full ROM and 4 shoulders (9%) had limited ROM at the time of latest follow-up. Similar results were found in the traumatic and atraumatic subgroups (Table 3). Strength Using a subjective strength scale (0-3: 0 = none, 1 = markedly decreased, 2 = slightly decreased, 3 = normal), at the time of latest follow-up, the mean strength score for the 43 shoulders was 2.6 (range, 1-3). Twenty-seven shoulders (63%) had normal strength, 15 shoulders (35%) had slightly decreased strength, and 1 shoulder (2%) had markedly decreased strength. For the 22 traumatic shoulders the mean strength score was 2.6 (range, 1-3), and for the 21 atraumatic shoulders the mean strength score was 2.6 (range, 2-3) (Table 3). ASES Scores Using the standardized ASES shoulder scale (0-100, with 100 being best), the mean ASES score for the 43 shoulders at latest follow-up was 91.4 (range, 59.86-100). The mean ASES scores for the traumatic and atraumatic groups were 91.1 (range, 59.86-100) and 88.8 (range, 59.86-100), respectively (Table 3). WOSI Scores Using the standardized WOSI index, the mean WOSI percentage score for the 43 shoulders was 91.1 (range, 72.9-100). The mean WOSI scores for the traumatic and atraumatic groups were 93.7 (range, 72.9-100) and 89.3 (range, 74.5-98.6), respectively (Table 3). Return to Sport At the time of the latest follow-up for the 40 patients in the study, 26 (65%) returned to the same level of sport, 5 (12%) returned to a limited level, and 9 (23%) did not return to their previous sport. On further study of the 9 patients who did not return to sport, 2 patients did not return because they had completed their collegiate eligibility, 1 patient had transferred schools, and 1 patient did not return for reasons unrelated to her shoulder. Therefore, of the remaining 36 patients only 5 patients were unable to resume athletic competition secondary to the condition of their shoulder. Thus, 31 of 36 athletes (86%) were able to return to sport. The 5 patients who were unable to return included a high school wrestler, a collegiate swimmer, a high-level recreational swimmer, a high school cheerleader, and a high school basketball player. Failures Using the ASES scoring system, there were 2 failures (4.7%) (score ≤70) when taking function and pain into account in our 43 shoulders at the time of latest follow-up. Because the ASES scale does not measure stability, failures can also be judged by clinical instability. Using the stability scale, 2 (4.7%) of the 43 shoulders were failures (score >5) at the time of latest follow-up. All 40 patients (100%) thought their surgery was worthwhile and they would have it again. Downloaded from ajs.sagepub.com at UNIV OF DELAWARE LIB on November 29, 2010 1718 Baker et al The American Journal of Sports Medicine Four shoulders (9.3%) met at least one of the criteria to be defined as a failure based on either the ASES score or the standardized stability scale. These 4 patients included a high school cheerleader, 2 female high school basketball players, and a collegiate football player. Only 1 of the patients sustained a traumatic reinjury postoperatively. The surgical findings included a patulous capsule anteriorly, posteriorly, and inferiorly in all 4 patients. Two patients had undergone previous thermal capsulorrhaphy procedures. The operative procedures performed by us included 2 capsulorrhaphies with suture only, 1 capsulorrhaphy with anchors, and 1 capsulorrhaphy with anchors and additional plication sutures. Only 1 of these patients opted for a revision procedure. The patient was a football player who had been treated previously with a thermal capsulorrhaphy by another surgeon. He underwent capsulolabral plication with suture and was able to return to the same level of sport until 2 years postoperatively when he sustained a traumatic anterior dislocation in a game. He experienced multiple subluxation episodes after this, despite playing in a brace. At revision diagnostic arthroscopy he was noted to have a Bankart lesion. He was successfully treated with an open inferior capsular shift with Bankart repair, rotator interval closure, and a Bristow procedure because of his 2 previously failed surgeries. Complications There were no neurovascular injuries, superficial or deep infections, or cases of adhesive capsulitis in the study population. DISCUSSION Neer and Foster20 first reported on their preliminary results of an inferior capsular shift to treat shoulders with involuntary inferior and MDI in 1980. An important distinction was made between the repairs of unidirectional anterior or posterior instability and the repair of a shoulder with MDI. The major pathologic feature of MDI was determined to be excessive inferior capsular redundancy. The authors introduced the concept of an inferior capsular shift designed to reduce the capsular volume on all sides by overlapping and reinforcing the capsule on the side of the greatest instability and restoring balanced tension to the inferior and opposite capsular side. Forty shoulders in 36 patients diagnosed with MDI were treated with a humerus-based open inferior capsular shift. Only one patient subsequently developed recurrent instability. Since then, several studies have reported high returns to sport in athletes after an open inferior capsular shift in patients with MDI of the shoulder.1-4,22 More recently, as arthroscopic techniques and technology have advanced, several authors have reported on the arthro­ scopic treatment of MDI.** Arthroscopy allows for improved visualization of associated intra-articular lesions and can aid the surgeon in correctly determining the instability **References 6, 8, 10, 11, 14, 15, 17, 18, 24, 25, 27. pattern.17 The arthroscopic techniques are based on the concept of the inferior capsular shift described by Neer and Foster20 to treat the primary condition of inferior capsular redundancy. In 1997 McIntyre et al17 reported on 19 patients with MDI, all of whom had been traumatically injured, who were treated arthroscopically with a multiplesuture technique. The average follow-up was 34 months (range, 25-52). Multiple sutures were used to shift the anterior and posterior capsule superiorly, thus eliminating the pathologic inferior capsular redundancy present in all patients. The average postoperative score was 91 of 100 on the Tibone and Bradley26 outcome scale. Thirteen of 14 patients (92.9%) returned to their previous level of competition, and there was one recurrence of instability that was treated successfully with a revision arthroscopic capsular shift. The authors thought that MDI represented a spectrum of pathologic changes and described 3 subgroups of patients with the diagnosis of MDI but with different pathologic entities seen at arthroscopy. The first group was composed of male athletes involved in contact sports who demonstrated anterior and posterior Bankart lesions. Male athletes with a Bankart lesion and associated increased posterior laxity, inferior laxity, or both, composed the second group. The third group of patients consisted of predominately female athletes with excessive global capsular laxity and a history of microtrauma. Treacy et al27 reported on 25 patients with atraumatic multidirectional instability treated with an arthroscopic capsular shift with transglenoid technique at an average of 60 months (range, 36-80) of follow-up. The average Bankart score was 95 (range, 50-100). All 8 athletes with remaining eligibility were able to return to sport. The authors noted a spectrum of injury and theorized that traumatic injuries superimposed on asymptomatic capsular laxity could result in symptomatic instability. They recommended that management should focus on treatment of both the traumatic labral tears and atraumatic capsular laxity for optimal results.27 In the largest published series of arthroscopic treatment of MDI, Gartsman et al8 reported on 47 patients at an average follow-up of 35 months (range, 26-67). Twenty-six patients developed instability atraumatically and 21 patients described a traumatic onset. All patients were noted to have a large capsular volume and an abnormal inferior capsule. A Bankart lesion was noted in 10 patients (21%), a frayed or separated inferior labrum was found in 5 patients (11%), and a separated or frayed posterior labrum was noted in 8 patients (17%). Pan-capsular suture plication was performed in all patients. Suture anchors were used to repair labral detachments when present or to plicate the capsule if the labrum was either deficient or absent. Goodto-excellent results were reported in 44 of 47 patients (94%) based on the Rowe score. One patient (2%) developed postoperative instability. Twenty-two of 26 patients (85%) returned to previous levels of sporting activity. Hewitt et al10 reported on 30 shoulders in 27 patients treated with an arthroscopic pan-capsular plication. The average follow-up was 57 months (range, 25-100). Patients requiring concurrent labral repair were excluded. Anteriorinferior instability was noted in 6 patients, posterior-inferior Downloaded from ajs.sagepub.com at UNIV OF DELAWARE LIB on November 29, 2010 Multidirectional Shoulder Instability Treatment 1719 Vol. 37, No. 9, 2009 instability in 4 patients, and global instability in 20 patients. Good-to-excellent results were noted in 83% of patients based on the Rowe score. Ninety-seven percent of patients returned to sport; however, 20% returned at a limited level. The majority of reports of shoulder instability correctly distinguish between traumatic unidirectional and classic atraumatic MDI of the shoulder. However, it is becoming increasingly recognized that there is a spectrum of disease when describing shoulder instability.3,13,27 Athletes often fall within this spectrum as they may have some element of generalized ligamentous laxity in addition to the repetitive microtrauma and stress on the capsule related to their athletic endeavors. Superimposed major traumatic injuries may result in symptomatic instability in the previously asymptomatic athlete. Pollock et al22 noted that there appeared to be more than one etiologic factor in the majority of their patients. Gartsman et al8 also described a spectrum of glenohumeral pathologic lesions, suggesting a variable and multifactorial origin of MDI. Although there were 22 shoulders with a traumatic cause for instability and 21 shoulders without a clear history of trauma in the present study, many athletes in both groups participated in overhead throwing sporting activities, which can inflict repetitive microtrauma on the glenohumeral capsular ligaments and thus further blur the distinction between the separate groups. Similar to other published reports, our study notes a wide variety of anterior and posterior glenohumeral lesions in addition to the universal findings of inferior capsular laxity. Bankart lesions were seen in 23 shoulders (53%) with and without associated anterior capsular redundancy. Posterior labral lesions including incomplete stripping and detachment were seen in 20 shoulders (47%). All patients in our series had anterior and posterior pathologic changes either through isolated labral lesions, isolated capsular redundancy, or a combination of both. In accordance with our findings and those of other authors, the clinical spectrum of MDI represents a wide variety of pathologic lesions seen at arthroscopy.8 Arthroscopic management of all observed pathologic lesions is critical to obtaining an optimal result. Repair of the labral detachments must also include the restoration of appropriate capsular tension.3 A capsulolabral plication with a capsular shift appropriately restores the capsular tension, reduces the redundant capsular volume, and balances the anterior and posterior bands of the inferior glenohumeral ligament. Plication of the capsule to the labrum also restores and augments the labral buttress, deepens the glenoid concavity, and increases stability through concavity compression.8,10 If the labrum is detached or deficient, suture anchors provide an efficient means to concurrently plicate the capsule and repair or restore the labrum. Suture anchors were used in 34 shoulders (79%) in this series. The rotator interval was closed in 10 shoulders in our series. Interval closure was performed if excessive inferior translation remained after performance of the pancapsulolabral plication. Only one shoulder in which rotator interval closure was performed rated as a failure. Gartsman et al8 performed rotator interval closure in 28 of 47 patients for the same indication. The authors believed repair of the rotator interval was an essential portion of their operative management. Treacy et al27 recommended rotator interval closure in all patients with MDI. Hewitt et al10 performed interval closure in only 2 of the 30 shoulders treated with pan-capsular plication. Their specific indication was a positive sulcus sign in adduction and external rotation. Four failures (9%) were identified on the basis of either an ASES score ≤70 or a stability score ≥5. As mentioned previously, all 4 shoulders demonstrated anterior, posterior, and inferior capsular redundancy as the operative finding. Because none of the 4 patients demonstrated any discrete labral tears, we were inclined to perform a pan-capsulolabral plication without suture anchors. Two patients were treated with pan-capsular plication with suture only, a third patient was treated with an anterior suture capsulorrhaphy and posterior capsulorrhaphy with anchors, and the fourth patient with an anterior suture capsulorrhaphy and posterior capsulorrhaphy with anchors and additional plication sutures. It is possible that had we used anchors for all capsulorrhaphies to perform a more aggressive capsular shift, these patients would not have had failed results. Consideration should be given to the use of suture anchors to ensure an adequate capsular shift to restore capsular tension and restore the capsulolabral buttress if there is any concern regarding possible residual capsular laxity. The rotator interval was closed in only one of the failed procedures. Additional rotator interval closure could have addressed any unrecognized residual inferior instability. An additional reason these patients could have had failed results was poor recognition of tissue quality. Half of these patients with failures had previous thermal capsular shrinkage procedures and might have been better served with an open operation. The senior author (JPB) has reported previously on finding a thin and attenuated capsule at revision surgery after thermal capsulorrhaphy of the shoulder.5 Of the 40 total patients in our study, 26 (65%) returned to the same level of sport, 5 (12%) returned to a limited level, and 9 (23%) were unable to return to their previous sport. Four patients did not return because of either loss of eligibility, transfer of schools, or other nonmedical-related reasons. Only 5 patients were unable to resume athletic competition secondary to the condition of their shoulder. Therefore, 31 of the 36 patients who desired to return were able to accomplish that goal. Our 86% rate of return to sport is similar to that of other previous reports from the literature for open surgery, which has documented return rates ranging from 84% to 94%.1−3,22 and for arthroscopic surgery, which has documented return rates ranging from 85% to 100%.8,10,17,27 Although the present study is retrospective, all patients presented for operative intervention because of inability to effectively compete in their athletic endeavors. The athlete’s ability to return to sport is perhaps the major indicator of success or failure of this procedure. Although objective measurements can be made regarding residual glenohumeral laxity, strength, and ROM, an athlete’s ability to return to competition may be a more pertinent outcome measurement in this population. Comparison of these results with those of other studies is difficult because of lack of a consistent definition of MDI16 in the literature. We defined multidirectional instability as instability in more than one direction (including Downloaded from ajs.sagepub.com at UNIV OF DELAWARE LIB on November 29, 2010 1720 Baker et al The American Journal of Sports Medicine inferior instability) based on the elicited history, physical examination, evaluation under anesthesia, and confirmatory findings at arthroscopy demonstrating inferior capsular redundancy as well as anterior and posterior lesions associated with instability. We included patients with lesions of both traumatic and atraumatic origin. Previous reports of arthroscopic repair have included only those lesions of traumatic17 or atraumatic origin, or eliminated patients requiring labral repair.10 Although all patients in this study carried the single diagnosis of MDI, a wide variety of pathologic lesions was seen at arthroscopy. This was similar to the report by Gartsman et al.8 We agree that the clinical spectrum of MDI may be represented by a spectrum of anatomical lesions.7 Limitations of our study include the lack of preoperative patient-reported scores and the heterogeneous study population, but these issues are inherent to most retrospective studies and can make comparisons between studies difficult. Arthroscopic repair of visualized labral detachments and combined capsulorrhaphy to restore capsular tension produced significant improvements in pain and stability in the athletes in our study. Intraoperative assessment is critical to determining not only the labral injury, but also the degree of capsular laxity. These findings dictate the method of repair and degree of capsular plication. The use of anchors for capsulolabral repair/capsulorrhaphy appears to be a safe option with low risk of recurrence, even for patients without discrete labral tears. Eighty-six percent of athletes were able to return to their sports. All patients were satisfied by the procedure and would have it again. In conclusion, arthroscopic repair in athletes with symptomatic MDI appears to be an effective, reproducible treatment option. References 1.Altchek DW, Warren RF, Skyhar MJ, Ortiz G. T-plasty modification of the Bankart procedure for multidirectional instability of the anterior and inferior types. J Bone Joint Surg Am. 1991;73:105-112. 2.Bak K, Spring BJ, Henderson IJP. Inferior capsular shift procedure in athletes with multidirectional instability based on isolated capsular and ligamentous redundancy. Am J Sports Med. 2000;28:466-471. 3.Bigliani LU, Kurzweil PR, Schwartzbach CC, Wolfe IN, Flatow EL. Inferior capsular shift procedure for anterior-inferior shoulder instability in athletes. Am J Sports Med. 1994;22:578-584. 4.Cooper RA, Brems JJ. The inferior capsular-shift procedure for multidirectional instability of the shoulder. 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