Arthroscopic Posterior Capsulorrhaphy for Osteoarthritis of the Shoulder Associated
with Posterior Instability: Two to Ten year results
ABSTRACT
INTRODUCTION: Two seemingly overlooked papers in the orthopaedic literature
provided the stimulus for this investigation. In 1981, Rowe and Zarins (2) presented a
series of patients with an unusual presentation of shoulder pain, which they treated with
capsulorrhaphy, achieving 94% good or excellent results. The patients had been seen
by various clinicians with failure to diagnose or sometimes various alternative
psychologic or neurologic diagnoses.
In 1983, Robert Samilson (3) described the importance of posterior instability and the
common appearance of posterior changes, such as posterior slope of the glenoid,
posterior Bankart tears and posterior erosion as a common accompaniment of
osteoarthritis.(1,4,5,6,7,8,9) He emphasized that delay in diagnosis of posterior
instability might be responsible for those changes.
As we began to see similar conditions in my practice, we began to think that there might
be a connection between these two findings; that perhaps persons with posterior
instability might go undiagnosed for years and not recognized until changes of
osteoarthritis began to occur as a result of shear forces on cartilage. (10,11) Although
much has been reported in orthopaedic studies about the effects of compressive forces
on articular cartilage, very little appears relating to shear forces as a cause of injury.
We postulate that once the mechanical effects of shoulder instability begin, shear
effects cause pathologic changes such as labral fragmentation and
chondromalacia. The subsequent inflammatory response may later accelerate the
process by virtue of the metabolic changes which act in concert with the mechanical
process to accelerate the changes of osteoarthritis. (1)
We postulated then, that treating the posterior instability in shoulders with early
osteoarthritis that have posterior instability might delay the progression or even halt the
progression of the disease. This paper is an attempt to examine that hypothesis. It is
not meant to state that all causes of shoulder osteoarthritis are caused by instability but
that there may be a group of patients who fit that category
METHODS
There were 25 patients in the group with a range of age of 44 to 74 years of age. The
median age at the time of surgery was 59. Eighty percent (20) were men, 20% (5)
were women. 56% had their dominant shoulder involved. 11.5% (3) had injury due to
work related incidence. All patients presented with painful various stages of
osteoarthritis or advanced chondromalacia of the shoulder and on clinical exam showed
evidence of posterior instability.
Fig. 1
1
(Fig.1)
No patient in this study had been operated previously with a Putti-Platt procedure. One
had a previous Bankart procedure done by the author, another had a Magnuson –Stack
procedure done by another surgeon 20 years previously. Two had previous anterior
dislocations treated non-surgically, one had an AC separation many years previously.
Another had an open reduction internal fixation of a humerus fracture four years prior to
surgery. No patient had any hardware impingement as confirmed by pre-op x-rays and
arthroscopic exam at the time of index surgery.
Each shoulder was treated with bilateral examination under anesthesia, arthroscopic
exam, debridement, removal of any loose bodies, chondroplasty and posterior
capsulorrhaphy. SLAP tears or partial thickness rotator cuff tears, when present, were
included, but any patient with anterior Bankart tears or full thickness rotator cuff tear
repairs were eliminated from the study.(12) On average, the 25 patients scored 7.5 on
the pre-op simple shoulder test and rated their pre-op pain about five on a scale of 0-10
on the visual analog scale
Many patients at the time of the study could have been considered candidates for
resurfacing or replacement arthroplasty. All patients in this series had some
osteoarthritis on the glenoid of the treated shoulder with at least Grade III and some
2
degree of Grade IV posterior chondromalacia with functional range of motion and
reasonably normal contours of the glenoid and humerus. (Reasonable contours is
defined as no flattening of the humeral head or large glenohumeral joint osteophyte
formation.) The humerus was usually involved with one grade less of chondromalacia
than the glenoid. During the earlier stages the wear pattern on the humerus tended to
be on the central or slightly anterior portion of its articulating surface. Some patients
had developed some posterior erosion or posterior slope of the glenoid. All patients had
X-ray or MR evidence of glenohumeral joint arthritis and evidence of primarily posterior
instability on pre-op and intraoperative exams.
Surgery began with an examination under anesthesia of both shoulders to assess range
of motion and to confirm the diagnosis of posterior instability. Arthroscopic treatment
included a subacromial exam and a thorough glenohumeral examination through
posterior and anterior portals, removal of any loose bodies, debridement, abrasion
chondroplasty using a full radius synovial resector to freshen bony surfaces to bleeding
bone, and to trim loose articular cartilage to stable margins. A capsulorrhaphy was then
done using a combination of monopolar radiofrequency treating selected areas with a
striping technique, then with suture augmentation using absorbable or non-absorbable
suture in selected areas to complete the shoulder stabilization. (12,13,14) Post
treatment exam under anesthesia showed improvement of the instability with negative
sulcus and drawer signs. No pain pumps were used in the study but each patient was
given a single intra-articular injection of bupivacaine 0.5% before leaving the operating
suite. The patient was placed in a well padded, abduction pillow sling (Don-Joy, Breg).
before leaving the operating room.
The post-operative management was divided into two phases, a six week recovery
period involving healing and range of motion, followed by a six week rehabilitation
period involving strengthening and return to use, after which patients were allowed
unrestricted activities, including sports. A strict post-operative regimen was developed
and used based on the author’s experience and that of Wilk and Andrews (15), with
sling wear for six weeks, pendulum exercises beginning the day after surgery, range of
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motion exercises beginning at the second through the sixth week and progressive
resistive exercises beginning at the sixth week with discontinuation of the sling. In most
cases physical therapy was augmented by a home exercise program. Controlled range
of motion during the healing phase was considered important to nourish the joint and
avoid stiffness. The goal was to reach functional, if not normal range of motion by the
end of the sixth week during the period when the capsule would be most stretchable.
(15,16)
RESULTS
Of the 25 patients, three were dropped from the analog pain and function scales test,
because they did not complete preoperative analog pain and function scales; however,
the same three were calculated in the Simple Shoulder Test as they had completed that
pre-op evaluation. All patients in this study had a pre-op and a post-op Simple Shoulder
Test performed at final follow up.
Statistical Analysis
SPSS (Statistical Package for the Social Sciences computer program) was used to
conduct the analysis. The paired-sample t-test was used to analyze the mean
differences for the analog pain and function scales as well as the Simple Shoulder Test.
Patient Satisfaction Form
(Fig. 2,
Fig. 3)
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Simple Shoulder Test (SST)
There was significant improvement in the SST score (p < 0.001). The patients
performed on average of 7.5 of the twelve functions on the SST before surgery and a
mean of 10.3 of the functions at the time of the last follow-up, with a mean difference of
2.8. Our sample size is small, but a side by side observation of the preoperative and
postoperative shoulder functions shows a noteworthy increase with all the functions
evaluated in the SST. The top four increases sleep comfortably (46.1%), wash opposite
shoulder (42.3%), lift 8 pounds to shoulder level (34.6%), and shoulder comfortable with
arm rested at side (30.8%). The four smallest increases in shoulder functionality are
place a coin on a shelf at shoulder level (7.7%), lift a pint of liquid to shoulder (7.7%),
carry 20 pounds at your side (11.5%), and work full-time at your regular job (11.5%).
(Fig.4)
VAS For Pain and Function
There was a significant decrease in pain of the shoulder at long-term follow-up.. The
mean initial pain scale was 5.22 ± 2.02 (range 1 to 7) and the mean follow up pain scale
was 2.87 ± 2.22 (range 0 to 8). The mean difference of the pain scale was 2.35 (p <
.001, 95% CI). There was also a significant increase in functionality of the shoulder at
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the time of the follow-up visit . The mean initial function scale was 4.35 ± 1.99 (range 2
to 8) and the mean follow up function scale was 8.57 ± 0.992 (range 5 to 10). The mean
difference of the function scale was 4.27 (p < .001, 95% CI). Overall this indicates that
the procedure was a success with these patients.
(Table 1)
Only four patients were unable to return to their previous level of work. One of these
had been a work injury. Of 25 patients, one reported that he was not satisfied with the
results of the procedure and would not have it again if the choice were given to him.
This patient has not come to a shoulder replacement or any further surgery. For
uncertain reasons he did not have an abrasion chondroplasty as part of his surgery. In
spite of that, he has managed to lead a very active life-style showing a significant
improvement in the post-op Simple Shoulder Test scores. Of the remaining 24, many
were enthusiastic and grateful about having had the procedure on their shoulder.
Twenty-two patients returned to “full activity including sports at the 80% or better level.
In some cases this included tennis, soft ball, basket ball. One had returned to national
level tournament amateur golf. One patient later came to having a shoulder
replacement. There were no infections, axillary nerve injuries, stiff shoulders, capsular
injuries or chondrolysis.
DISCUSSION
Up to now the only surgical treatments available for osteoarthritis of the shoulder have
been capsular release (17) and fascial (18) or replacement arthroplasty (19) when
conservative means such as physical therapy with oral anti-inflammatories or injections
have failed. Complications of replacement arthroplasty in a young patient, a major
surgery, often requiring later revisions has not been a satisfactory choice. Our
approach to treatment of the problem offers two advantages. First it does not burn any
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bridges for future treatment. Secondly, management can be totally arthroscopic. Even a
few years spent avoiding replacement arthroplasty can be a definite advantage. So far
as we know, no other such approach treating arthritic shoulders has been described.
While arthroscopic fascial arthroplasty has been described as a possible treatment for
this condition, the results have not been durable or consistent, and the procedure is
difficult for even the experienced surgeon to perform. Ours is a simple approach to this
perplexing problem.
There is a learning curve of how much and where tightening should be achieved, but
the use of thermal energy thus allows some forgiveness of this problem, because it
allows stretching without tearing the tightened capsule.. It could be done using an open
procedure (28) or an arthroscopic suture capsulorrhaphy, the latter being the preference
of those two choices because open capsulorrhaphy can often over-tighten the capsule.
Over-tightening (29) is a complication which could doom the success of the procedure.
The posterior capsule, however, is generally more forgiving than the anterior capsule.
To this author’s knowledge reports of arthritis resulting from over-tightening have been
due to anterior tightening (e.g. Putti-Platt). A shoulder already on the pathway to
replacement has little to lose in the face of potential gain.
A paradox existed with the Simple Shoulder Test with other parts of the post op
evaluation in which three patients appeared to have a lesser score on their Simple
Shoulder Test post op than pre-op but had improved function or less pain on the visual
analog scale and expressed satisfaction with having had the procedure. Part of this
paradox can be explained by question number 12 and the fact that many office workers
have little physical demand on their shoulders are able to work whereas a laborer’s
work can be significantly affected by shoulder osteoarthritis. We suggest that question
12 on the simple shoulder test be changed to “ Able to perform maintenance and repair
tasks around the home”. Since many work positions are non-physical, “return to work”
may not be a reliable indication of physical capacity, but almost everyone does routine
household chores. The patients which did show a discrepancy in the simple shoulder
test did notice subjective improvement in their overall function. One of these was
7
enthusiastic about the surgery, saying that it made a “huge difference from his preoperative condition” All except the one mentioned above would have the surgery again
if given the choice. We developed the “Patient Satisfaction Questionnaire” to help
correct this SST discrepancy (Fig.3)
We feel there were no failures in this series of patients with the methods described. The
one patient who did come to a shoulder replacement gained seven years of relief before
requiring a hemi-arthroplasty. That patient was grossly overweight and had become
wheelchair bound, thereby relying heavily on her upper extremities for mobility, placing
added stress on an already impaired shoulder.
This study has some weaknesses. The patient number is limited. The study is not
blinded, being presented by a single author and surgeon. The procedure is not
compared with other methods of treatment. The analysis of the results is accomplished
with a visual analogue scale as to pain and function, a questionnaire evaluating post-op
activity level, quality of life and patient satisfaction and the Simple Shoulder Test. For
purposes of simplicity and convenience in a community office practice other more
complex shoulder scales were not used. In a pre-operative trial many of our patients
refused to answer the mental health parts of SF36 questionnaire making its use
impossible. The Simple Shoulder Test and Visual Analogue Scale have been shown to
be satisfactory indicators of success in other clinical studies. Patient satisfaction is
considered a good indicator of success or failure. (30)
CONCLUSION
This study demonstrates that at least in some cases posterior instability may be a
cause, not necessarily a result of osteoarthritis. This condition of posterior instability in
its early stages may require a high index of suspicion on the part of the evaluating
surgeon. We present a simple approach to treatment for many patients who may find
simple relief of a very difficult and disabling problem while still in the productive years of
their life.
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List Of Figures
Number
Fig. 1 – AGE DISTRIBUTION –
The patients’ median age at the time of surgery was 53 ± 7 years
(range 37 to 71). Twenty-one were men, five were women.
Fig. 2 -- PATIENT SATISFACTION FORM
Fig. 3 -- SIMPLE SHOULDER TEST FORM
Fig. 4 – SHOULDER FUNCTIONS TEST –Fig. 4 - There was significant
improvement in the SST score after surgery. Most notable increases in activities
were: Sleep comfortably, wash opposite shoulder, lift eight pounds to shoulder level
and shoulder comfortable with arm rested at side. Three most common activities that
patients could do before surgery were place a coin on a shelf at shoulder level, lift a
pint to shoulder and carry 20 pounds at your side, therefore they show the least
change post-operatively.
Table 1 -- VAS PAIN AND FUNCTION – Table 1 - There was a significant decrease
in pain of the shoulder at the follow-up visit. There was also a significant increase in
functionality of the shoulder at the time of the follow-up visit. Overall it appears that
the procedure was a success with these patients.
12