Name: Arthroscopic Capsulorraphy for Multi-Directional Instability
Uploaded: 2002-05-17T00:00:00Z
Channel: Arthrex

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VCD-1057 | A | Arthroscopic Capsulorraphy for Multi-Directional Instability

Anthony A. Romeo

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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Arthroscopic Capsulorraphy for Multi-Directional Instability

Arthrex presents an arthroscopic shoulder capsule for multidirectional instability. The procedure is performed by Doctor Anthony Romeo in Chicago, Illinois. While many patients present with instability in one direction, primarily anterior instability, we also have patients who present with an instability in the posterior direction and less commonly, those patients who present with an instability in more than one direction, which we've described as a multidirectional, unstable shoulder. These offer us the greatest challenge in terms of stabilizing the shoulder, and yet providing the opportunity for them to return back to normal functional activities. The case that we have today is the case of a woman who fell injuring her shoulder, and on clinical examination, demonstrates instability in an anterior Your direction, as well as an inferior direction with some pathologic laxity posteriorly, thereby defining the multidirectional instability of a right shoulder. In addition, this woman, when she fell, injured part of her rotator cuff, the subscapularis tendon, which contributed to the complexity of the management of her problem, which was done entirely arthroscopically. The surgical treatment, whether done open or arthroscopically, is to reduce the overall capsular volume. If we are going to address this problem with arthroscopic techniques, then we need to perform at least a 270 degree reduction in the capsular volume, but may in fact include up to 360 degree treatment of the glenohumeral joint and the more severe cases of multidirectional instability. My personal preference when the capsular laxity involves the inferior aspect of the shoulder joint, and one primary direction, such as anterior, is to perform a 270 degree capsular plication, but leave the superior aspect of the capsule alone, which typically does not play a significant role in this patient population. To perform a 270 degree capsular plication, the surgeon should begin at the inferior aspect of the glenohumeral joint. This is at the 6:00 position. The surgeon will need to have a strategy to establish two cannulas through the posterior aspect of the shoulder, and two cannulas through the anterior aspect of the shoulder, to be able to address the entire shoulder joint. My preference, because of the need for the meticulous suture plication, is to establish an eight millimeter cannula at the posterior inferior aspect of the glenohumeral joint, and then either a six or an eight millimeter cannula at the anterior inferior aspect of the glenohumeral joint. We're going to need to create a posterior portal. Here's the posterior corner or approximately the 7:00 position. And so with this cannula, we'll be able to address problems all the way into this posterior inferior corner. And then we're going to dilate this up with a cannula dilation system. These are tools that will allow us to sequentially enlarge the hole that will then finally match the size of our cannula. Now we'll take our cannula. Now this is an eight millimeter cannula and lock into place. And then we can feed this directly over our Weisinger rod. And by doing that we maintain the portal at all times in the same position. We don't create problems with larger holes in our capsule or multiple holes in our capsule. This is a screw in cannula, so we really should advance it by turning it completely. And this will also pull back the soft tissues once we enter into the joint. Again improving our visualization. So here we are into the joint and we just keep rotating and the capsule will back up for us. And then we'll start with our repair beginning inferiorly. So even before we do our capsular plication maneuvers posteriorly, we're going to just take a rasp and we're going to just kind of take this. And when we get these little frayed edges here, what that is, is that's again irritating the synovium, which should create a nice healing response to go along with the bleeding bone up front so that we can get adequate repair. I begin with suture at the 6:00 position using a Corkscrew lasso. A SutureLasso is a firm cannulated needle, for all practical purposes, that has the ability to pass suture out of the tip of this sharp instrument. It comes in a number of configurations, including a 45 degree straight angle, a 90 degree angle, as well as a right and left Corkscrew design. In a right shoulder. This would be a left Corkscrew lasso, passing 1 to 1.5 centimeters lateral to the labrum, through the capsule, and then out of the capsule again, and then through the labrum, performing a suture tuck to avoid injury to the axillary nerve, which is within one centimeter from the inferior capsule. The surgeon should pass the sharp instrument through the capsule, then rotate the instrument so that the tip of the instrument stays directly below the capsule. By keeping the tip of the instrument directly below the capsule, injury to the axillary nerve is avoided. The loop of suture is then advanced into the glenohumeral joint and then brought out one of the anterior cannulas. The suture is then passed through the loop, preferably a number two braided nonabsorbable suture, and then the loop suture within the Corkscrew is used to pull this new suture through the labrum, around the capsule, and then out the 7:00 portal. We want to put in a few stitches, and we don't want to tie it right now, because it's going to really close off our space. And we'll take our stitch and we'll pass this into the joint and we'll grab our stitch and just make sure we don't unload what we've already done. Take the knot pusher out. And then again to not tangle up our stitches. What we'll do is we'll take a small Weisinger rod back out our cannula. We'll pull out our stitches. We'll put a hemostat on these so we know exactly which ones they are. And we'll leave that out of the cannula and we'll put our cannula back into place. This technique is continued around posteriorly to involve the 7:00 position and then the 8:00 position. There is a new stitch that's available that is a synthetic polyester. And it has been configured into a suture which is called FiberWire. It's a very strong suture, in fact, the fact the same size. Number two, suture is actually the strength of a number five using the FiberWire. So we're going to go ahead and tie my stitches. And what I'd like to do here is I'm going to come through and I'm going to tie from the back side, put our knot pusher down to make sure we're putting our post on the soft tissue side. We'll tie a left handed Duncan loop. Contrary to what you may have heard, braided suture can be tied with a slip knot and it will slide. So here, we'll dress our knot. We have a nice firm slip knot, which will have enough friction to stay in place once we put it there. We'll slide over our post. We don't try to drag it down. We push it down the post and we'll push that on down. And you can see how we've placated that right up to the rim of the glenoid. We'll see a little bit better in a minute. But this is a nice snug knot. I'll put a half hitch on and I'll pass point here which will help lock in my my stitch. So as I pass point, that puts a very snug knot down. Now typically we can just relax. The knot will not undo. At that point. We can switch posts if in fact it does slide back on us. If there's too much tension, we can go ahead and put another half hitch on the same side to create more friction, but still a slip knot to keep it into the place that we want. Well, you can see as we've done the bumper back to there, and now we're going to really do our anterior repair. I then proceed with the anterior inferior plication. Our goal is to try to solve the inferior laxity from the six around to the 8:00 position, and then anterior from the six to the 4:00 position, and then we'll proceed further anteriorly up to the 2:00 position. And then our final stage is to close the rotator interval. So here we started. This is a biceps tendon is here. Go around posteriorly down the back side. And our SuturePlate begins back there. Comes underneath. There's the 6:00 position. 5:00 position, 4:00 position coming around to the 3:00 position. Having that secured down. So if we look underneath the biceps again going across the joint. There's our posterior portal or where it used to exist. Down around inferiorly and then looking straight on down to the 3:00 position. Here's the subscapularis tendon. So that's the 3:00 position. And our final stage will be to close this rotator interval that we see up in here. And we'll take the middle glenohumeral ligament subscapularis border and close that down. The superior ligament should immediately below me. Here's the subscapularis, the subscapularis recess. And as we follow the subscapularis on out, here's the Here's the insertion point on the subscapularis, where we had some concerns over a partial thickness tear. We've taken a stitch and put that around that area, and it's very difficult to actually identify a defect in the subscapularis from this position at this time. In my opinion, closure of the rotator interval is a critical step in any patient with multidirectional instability. It has been shown in biomechanical studies that closure of the rotator interval will restrict inferior laxity or translation, as well as posterior inferior laxity. Two of the critical areas of increased pathologic laxity that we are trying to solve with our stabilization procedure tools such as the Penetrator, allows us to reach through the soft tissue and grab a suture, and then again using our cannula or an 18 gauge needle or the Penetrator. Again, we can reach through a separate layer of the soft tissues, typically the superior glenohumeral ligament and middle glenohumeral ligament, and then tie the two limbs of the suture. This can be done within the joint, or it can be done in a somewhat of a semi-blind fashion, just outside of the capsular layer. So here we are in the back of the shoulder. Here is the top. There's the biceps tendon. We'll come around posteriorly. And remember we had that view where everything seemed to fall off the edge of the glenoid. And now we do not have an ability to see any of that. We can't get down below. We can't move up in the front. It all is brought up. And then in our final stage, we close the rotator interval. As we can see right there, there's actually two stitches coming across there we can't get in. So the rotator interval has been tightened also. And with all of that being done we've reduced or eliminated any inferior translation. She'll have no anterior translation, and whatever pathologic posterior translation she had will also be resolved. The head is centered because we've worked on the circumference of the joint. We have an over tightener in one direction or the other, and we repair the subscapularis before closing our rotator interval with the side to side repair. So that completes our surgical repair. Preoperatively. We had a sulcus sign. Here's our sulcus right here. There's no movement. I can't I can't pull down at all posteriorly. No movement anteriorly. There's no movement. Her rotation has been restricted. Here is her external rotation which is approximately ten degrees, which is typical for a rotator interval closure. We can abduct the arm. Here is our external rotation. Here internal rotation is to here. And again her primary component of instability was anterior. And there is no remaining anterior laxity in laxity in her shoulder, posteriorly or inferiorly, it will not come down. So here she is with her external rotation to here. So internal rotation to there. External rotation to there. Bring her arm up there. And again. No remaining anterior translation. No inferior translation. For information on the Arthrex surgical skills training programs, contact Arthrex at 1-800-933-7001 or visit the Arthrex website at arthrex.com. This program was sponsored by an educational grant from Arthrex incorporated.

Arthroscopic Capsulorraphy for Multi-Directional Instability

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