Arthroscopic Capsular Plication Research Articles

Treatment of Hip Microinstability with Arthroscopic Capsular Plication: A Retrospective Case Series.

Hip microinstability is defined as hip pain with a snapping and/or blocking sensation accompanied by fine anatomical anomalies. Arthroscopic capsular plication has been proposed as a treatment modality for patients without major anatomic anomalies and after failure of properly administered conservative treatment. The purpose of this study was to determine the efficacy of this procedure and to evaluate potential predictors of poor outcome. A review of 26 capsular plications in 25 patients was conducted. The mean postoperative follow-up period for the remaining patients was 29 months. Analysis of data included demographic, radiological, and interventional data. Calculation of pre- and postoperative WOMAC (Western Ontario and McMaster Universities Osteoarthritis) index was performed. Pre- and postoperative sports activities and satisfaction were also documented. A P<0.05 was considered significant. No major complications were identified in this series. The mean pre- and postoperative WOMAC scores were 62.6 and 24.2, respectively. The WOMAC index showed statistically significant postoperative improvement (P=0.0009). The mean satisfaction rate was 7.7/10. Four patients with persistent pain underwent a periacetabular osteotomy. A lateral center edge angle ≤21° was detected in all hips at presentation. We were not able to demonstrate any difference in postoperative evolution with regard to the presence of hip dysplasia (P>0.05), probably because the sample size was too small. Capsular plication can result in significant clinical and functional improvement in carefully selected cases of hip microinstability.

Multidirectional Instability of Shoulder Joint: A Review

Introduction: The biomechanics of the shoulder joint are complex. To allow a functional range of motion, stability is sacrificed. Glenohumeral joint stability is maintained by static and dynamic stabilizers. Static stabilizers are non-contractile structures including capsulolabral structures and bony glenoid while dynamic stabilizers are contractile structures including rotator cuff, conjoint tendon, and long head of the bicep. The objective of this review is to elaborate on multidirectional instability (MDI) of the shoulder joint and the management of this disorder. Review: Laxity can be affected by hereditary and genetic factors. This can be seen for example in generalized joint laxity which often manifests in the shoulder as MDI. Mutations in collagen genes can cause altered collagen structure, mostly in collagen Type I, resulting in smaller and longer collagen cells. Abnormalities could be found in mRNA synthesis or amino acid transcription for collagen protein, resulting in amino acid content variation. Alterations in fine-tuning mechanism, cleavage process, ionic interaction, cross-linking and metabolism could also result in collagen quality variation. Genetic factors could also cause elastin overproduction rate or amount. Elastin amino acid content alterations could also be affected genetically. These alterations produced a looser static stabilizer. Even so, shoulder joint have multiple static stabilizers and the individual having hereditary laxity does not always have problems related to joint laxity. If the laxity caused problems, it is usually in the form of pain, discomfort, or disruption in shoulder joint function. To compensate for the loose static stabilizer, rehabilitation should be optimized on the contractile, musculature structure of the glenohumeral joint. Besides rehabilitation, capsular shift procedure could also be performed as management of the affected joint by open surgery, arthroscopic capsular plication, or arthroscopic thermal capsulorrhaphy. Conclusion: Based on the review conducted, reoperation rates for open surgery, arthroscopic technique, and thermal technique were approximately 10%, 5%, and 15% subsequently. This should be considered when choosing the appropriate surgery method for MDI management if rehabilitation on contractile structures does not improve patients’ condition.

Rotator cuff muscle imbalance associates with shoulder instability direction.

Although muscle weakness and/or imbalance of the rotator cuff are thought to contribute to the development of shoulder instability, the association between muscular dysfunction and shoulder instability is not completely understood. The purpose of this study was to evaluate rotator cuff and deltoid muscle cross-sectional areas in different types of shoulder instability (anterior, posterior, and multidirectional instability (MDI)) and to determine the associations between muscular imbalance and shoulder instability direction. Preoperative magnetic resonance images of patients with shoulder instability who subsequently underwent arthroscopic glenohumeral labral repair or capsular plication were evaluated. Shoulder instability was classified into three categories by direction: (1) anterior, (2) posterior, and (3) MDI. The rotator cuff (supraspinatus, subscapularis, and infraspinatus+teres minor) and deltoid (anterior and posterior portions, and total) muscle areas were measured on T1 sagittal and axial slices, respectively. The ratios of the subscapularis to infraspinatus+teres minor area (SSC/ISP-Tm ratio) and the anterior deltoid to posterior deltoid area (AD/PD ratio) were calculated to quantify the transverse force couple imbalance. A total of 189 patients were included, where each group consisted of 63 patients. The infraspinatus+teres minor muscle area was smaller than the subscapularis muscle area in the anterior instability group (P=0.007). The subscapularis muscle area was smaller than the infraspinatus+teres minor muscle area in the posterior instability and MDI groups (P≤0.003). The anterior deltoid muscle area was smaller than the posterior deltoid muscle area in all groups (P≤0.001). The SSC/ISP-Tm ratio in the anterior instability group (1.18±0.40) was higher than that in the posterior instability and MDI groups (0.79±0.31 and 0.93±0.33, respectively; P<0.001). There was no difference in the AD/PD ratio among the 3 groups. Patients with anterior instability have smaller muscle area of the posterior rotator cuff as compared with the anterior rotator cuff. In contrast, patients with posterior instability and MDI have smaller muscle area of the anterior rotator cuff as compared with the posterior rotator cuff. Thus, the direction of shoulder instability is associated with rotator cuff muscle area.

Multidirectional instability of the shoulder: surgical techniques and clinical outcome.

Multidirectional instability of the shoulder has a complex pathoanatomy. It is characterized by a redundant glenohumeral capsule and increased joint volume. Subtle clinical presentation, unclear trauma history and multifactorial etiology poseses a great challenge for orthopedic surgeons in terms of diagnosis. Generally accepted therapeutic approach is conservative and the majority of patients achieve good results with rehabilitation. In patients who are symptomatic despite appropriate rehabilitation, surgical intervention may be considered. Good results have been obtained with open inferior capsular surgery, which has historically been performed in these patients. In recent years, advanced arthroscopic techniques have taken place in this field, and similar results compared to open surgery have been obtained with the less-invasive arthroscopic capsular plication procedure.

Cleft Sign and Bone Marrow Edema of the Pubic Symphysis Are Associated With Sports and Bony Morphology in Patients With Femoroacetabular Impingement and Labral Tears.

Background:The cleft sign (CS) and bone marrow edema (BME) are considered magnetic resonance imaging (MRI) findings signifying a pubic pathology, which is associated with groin pain; however, their relationship with bony morphology related to femoroacetabular impingement (FAI) has not been established.Purpose:To investigate the prevalence of CS and BME in symptomatic patients with acetabular labral tears and assess their possible association with bone morphology and sport-specific activities.Study Design:Cross-sectional study; Level of evidence, 3.Methods:This study enrolled 418 patients (469 hips) undergoing hip arthroscopic surgery for labral tears. Also included were patients with labral tears in the setting of either hip dysplasia or borderline hip dysplasia who were undergoing endoscopic shelf acetabuloplasty combined with hip arthroscopic labral repair, cam osteoplasty, and capsular plication. All patients were screened for superior CS (SCS), inferior CS (ICS), and BME of the ipsilateral side of the pubis using 3-T MRI. We measured the following angles: lateral center edge (LCE), Sharp, Tönnis, vertical-central-anterior, and alpha. Then, we evaluated the relationship between patient characteristics and abnormal findings on MRI scans (preoperatively vs 1 year postoperatively).Results:An overall 397 hips were included: 200 in men and 197 in women (mean ± SD age, 35.3 ± 16.0 years). There were hips in 214 athletes (53.9%) and hips in 183 nonathletes (46.1%). MRI findings revealed SCS, ICS, and BME in 18 (4.5%), 13 (3.3%), and 34 hips (8.6%), respectively. Abnormal MRI findings at the pubis were seen more often in athletes than nonathletes (23.8% vs 3.3%), and contact sports athletes had the most frequent abnormalities. There was no SCS in patients with an LCE angle <22°. SCS was more frequently seen in those who had an alpha angle ≥71°. More than 60% of abnormal findings at the pubis diminished after arthroscopic surgery that included FAI correction and labral repair.Conclusion:In patients with labral tears, CS and BME were seen more frequently in athletes versus nonathletes, especially contact athletes with FAI-related bony abnormalities. More than 60% of abnormal MRI pubis findings resolved after arthroscopic treatment of FAI.

Arthroscopic Capsular Plication for Multidirectional Shoulder Instability in Hypermobile Ehlers-Danlos Syndrome Patients

Patients with hypermobile Ehlers-Danlos syndrome commonly present with painful shoulder disorders mostly represented by a multidirectional instability and with often painless episode of atraumatic shoulder dislocation and/or subluxation. Because of the generalized soft tissue fragility, most of the surgical treatments of shoulder instability, as the Bankart repair or the Latarjet procedure becomes not effective, exposing a risk of failure. Then, capsular plication has to be considered in order to reduce the articular joint volume and to diminish the mobility of the joint. Two main benefits of this surgical procedure are that it doesn’t modify the anatomy or damage the labrum or cartilage that is healthy. The purpose of this Technical Note is to present the arthroscopic capsular plication for the treatment of patient with hypermobile Ehlers-Danlos syndrome, which is associated with a multidirectional shoulder instability.

Endoscopic Shelf Acetabuloplasty Concomitant With Labral Repair, Cam Osteoplasty, and Capsular Plication to Treat Acetabular Dysplasia in Artistic Athletes: A Case Series.

Background:Knowledge of clinical outcomes and return to artistic activities after endoscopic shelf acetabuloplasty (ESA) for acetabular dysplasia in artistic athletes is lacking.Hypothesis:Hip arthroscopic surgery including ESA will enable artistic athletes to return to their activities with a high success rate, significantly improved acetabular coverage, and preserved joint cartilage.Study Design:Case series; Level of evidence, 4.Methods:We reviewed 28 hips in 23 female artistic athletes (14 ballet, 9 rhythmic gymnastics, 4 dance, and 1 baton twirling) who underwent arthroscopic labral preservation, capsular plication, and ESA. Their mean age was 25.8 ± 10.2 years. Preoperatively, all patients had generalized joint laxity (Beighton score, 7.1 ± 1.8). We evaluated preoperative and postoperative radiographs and outcome scores including the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), International Hip Outcome Tool 12 (iHOT-12), Vail Hip Score (VHS), and Hip Outcome Score–Sports (HOS— Sports). Statistical analysis was performed using paired t tests and Bonferroni correction.Results:The mean follow-up was 32.5 ± 12.5 months. The mean lateral center-edge angle significantly increased from preoperatively (15.7° ± 5.3°) to postoperatively (39.8° ± 8.2°; P < .001) and at the final follow-up (33.7° ± 8.6°; P < .001). The vertical-center-anterior angle significantly improved from preoperatively (16.2° ± 8.8°) to final follow-up (33.6° ± 8.0°; P < .001). All hips maintained a Tönnis grade of 0 or 1 at the final follow-up. Overall, 20 patients (87%) were able to return to their preinjury level. All outcome scores improved from preoperatively to postoperatively: mHHS, from 68.5 ± 18.1 to 88.3 ± 18.5; NAHS, from 50.8 ± 17.7 to 69.0 ± 11.4; iHOT-12, from 36.9 ± 19.3 to 75.2 ± 19.8; VHS, from 53.8 ± 13.7 to 79.4 ± 19.4; and HOS--Sports, from 59.9 ± 17.0 to 79.6 ± 21.3 (P < .001 for all). In total, 3 patients could not return to artistic activities as the result of postoperative deep gluteal syndrome.Conclusion:ESA concomitant with labral repair, cam osteoplasty, and capsular plication to treat dysplastic hips in patients with joint laxity enabled artistic athletes to return to their activities with a high success rate.

Revision Hip Arthroscopy in the Borderline Dysplastic Population: Reporting Outcomes With Minimum 2-Year Follow-up, With a Subanalysis Against a Propensity-Matched Nondysplastic Control Group

Background: Hip arthroscopy in patients with borderline dysplasia continues to be surrounded by controversy. Even more controversial is the management of the failed hip arthroscopy in this population. There is a paucity of studies in contemporary literature regarding outcomes after arthroscopic revision surgery. Purpose: (1) To report minimum 2-year patient-reported outcome (PRO) scores in patients with borderline dysplasia who underwent revision hip arthroscopy and (2) to compare these PRO scores with those of a propensity-matched control group without dysplasia who underwent revision hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: Data were prospectively collected between August 2009 and November 2017. Inclusion criteria were revision arthroscopic surgery, capsular plication, and baseline and minimum 2-year follow-up for the following PROs: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Patients with Tönnis grade >1 or previous hip conditions were excluded. Two groups were created: a study group with borderline dysplasia (lateral center-edge angle [LCEA], 18°-25°) and a control group without dysplasia (LCEA, 25°-40°). Groups were propensity-matched in a 1:3 ratio for sex, age, body mass index, and follow-up time. Results: A total of 22 revision borderline dysplastic hips (21 patients) had a minimum 2-year follow-up during the study period. Patients in this group reported significant improvements for all PROs from baseline and achieved the minimal clinically important difference (MCID) for the mHHS at a rate of 70%. Moreover, 21 borderline dysplastic hips (21 patients) were matched to 63 control hips (63 patients). Mean LCEA for the study and control groups was 22.6 ± 1.7 and 32.0 ± 5.0, respectively. Both groups reported similar improvement in all PROs. The rate for achieving the MCID for the mHHS and VAS was similar between groups; however, the control group had higher rates of meeting the MCID for the HOS-SSS and NAHS (P = .042 and P = .025, respectively). The rates of conversion to hip arthroplasty were 7.9% (n = 5) in the control group and 23.8% (n = 5) in the borderline dysplasia propensity-matched group (P = .052). The rate of re-revision arthroscopy was 11.1% (n = 7) in the control group and 19.0% (n = 4) on the borderline dysplasia group (P = .350). Conclusion: After revision hip arthroscopy, significant improvement was obtained for all PROs in patients with borderline dysplasia at a minimum 2-year follow-up. Moreover, outcomes, patient satisfaction, the rate for achieving the MCID for the mHHS and VAS, and the rate for secondary surgery were similar to those of a propensity-matched control group without dysplasia. Nevertheless, there was a nonsignificant trend toward higher secondary procedures in the study group; therefore, arthroscopic revision surgery in the borderline patients should be approached with measured prognosis.

Arthroscopic management with labral preservation, femoral osteoplasty, and capsular plication in patients with borderline hip dysplasia. Results of a matched-cohort study at minimum twoyear follow-up.

The purpose of this study was to assess intra-operative findings, surgical procedures, and outcomes in a cohort of patients with borderline hip dysplasia treated with arthroscopic labral repair, femoral osteoplasty, and capsular plication, and compare these outcomes with those of a rigorously matched control group without dysplasia. Data were prospectively collected and retrospectively reviewed for patients with a lateral center-edge angle between 20 and 24° who underwent hip arthroscopy surgery between 2014 and 2018. Labral, chondral status, psoas impingement, ligamentum teres, and cam morphology were evaluated. Patient-reported outcomes (PROs) scores included modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living Subscale (HOS-AVD) and Hip Outcome Score Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (IHOT-12). Clinical relevance was measured with the minimal clinical important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB). Twenty patients met the inclusion criteria. An age- and sex-matched control group of 40 patients was also selected. Arthroscopic intra-operative findings were similar between cohorts. At a mean follow-up of 50months in the borderline hip dysplasia cohort, and 52months in the control cohort, there was a significant improvement in PROs in both cohorts, and no significant differences could be detected at the latest follow-up. The difference in frequency of patients achieving the MCID, PASS, and SCB was not statistically significant between cohorts. With strict patient selection criteria, hip arthroscopy may be a beneficial approach in patients with borderline hip dysplasia.

Arthroscopic iliac crest bone grafting in recurrent anterior shoulder instability: minimum 5-year clinical and radiologic follow-up

PurposeTo investigate the clinical and radiologic mid- to long-term results of arthroscopic iliac crest bone-grafting for anatomic glenoid reconstruction in patients with recurrent anterior shoulder instability.MethodsSeventeen patients were evaluated after a minimum follow-up of 5 years. Clinical [range of motion, subscapularis tests, apprehension sign, Subjective Shoulder Value (SSV), Constant Score (CS), Rowe Score (RS), Walch Duplay Score (WD), Western Ontario Shoulder Instability Index (WOSI)], and radiologic [X-ray (true a.p., Bernageau and axillary views) and computed tomography (CT)] outcome parameters were assessed.ResultsFourteen patients [mean age 31.1 (range 18–50) years] were available after a follow-up period of 78.7 (range 60–110) months. The SSV averaged 87 (range 65–100) %, CS 94 (range 83–100) points, RS 89 (range 30–100) points, WD 87 (range 25–100) points, and WOSI 70 (range 47–87) %. The apprehension sign was positive in two patients (14%). One patient required an arthroscopic capsular plication due to a persisting feeling of instability, while the second patient experienced recurrent dislocations after a trauma, but refused revision surgery. CT imaging showed a significant increase of the glenoid index from preoperative 0.8 ± 0.04 (range 0.7–0.8) to 1.0 ± 0.11 (range 0.8–1.2) at the final follow-up (p < 0.01).ConclusionArthroscopic reconstruction of anteroinferior glenoid defects using an autologous iliac crest bone-grafting technique yields satisfying clinical and radiologic results after a mid- to long-term follow-up period. Postoperative re-dislocation was experienced in one (7.1%) of the patients due to a trauma and an anatomic reconstruction of the pear-shaped glenoid configuration was observed.Level of evidenceIV.

Capsular Plication for Symptomatic Borderline Hip Dysplasia

Hip arthroscopy indications have expanded beyond the treatment of the pathologies associated with femoroacetabular impingement. Other pathologies that are being increasingly treated with hip arthroscopy include borderline hip dysplasia. This chapter defines borderline hip dysplasia, discusses the indications for arthroscopic capsular plication, describes the surgical technique, and summarizes the results of the literature for the arthroscopic treatment of borderline hip dysplasia. Although hip arthroscopy can be successfully used to treat borderline dysplastic hips with a capsular plication technique, outcomes are less predictable compared to outcomes after femoroacetabular impingement surgery. Optimal results appear to occur in a younger population who undergo labral preservation and capsular imbrication.

Arthroscopic Repair for Posterior Shoulder Instability: Case series and surgical outcome

PurposeThis study evaluates outcomes of a consistent arthroscopic stabilization technique for recurrent posterior instability. Methods79 shoulders with symptomatic posterior instability treated with arthroscopic repair and evaluated at a follow-up of 36 months. The mean age was 25.4 years of which 66 males and 13 females, and in 75% the dominant shoulder was affected. A known traumatic injury had occurred in 80%, with 25% having a documented dislocation. Arthroscopic repair was performed through an anterosuperior 12 O’clock viewing portal. Suture anchor repairs were performed in 60 cases and plication to the intact labrum in 19. A shoulder immobilizer was used for 4 weeks, followed by progressive range of motion, weightlifting at 3 months and return to contact sports at 6 months. The 79 cases had complete pre-op and post-op shoulder outcome scores. ResultsSignificant improvement from preoperatively to final follow-up was seen for ASES scores, from 58 to 93. All patients returned to their previous level of athletic activity. Two patients reported postoperative instability; none required reoperation. There were no other postoperative complications. ConclusionsThis study represents a consecutive series of patients with recurrent posterior instability undergoing arthroscopic posterior stabilization. In this population arthroscopic posterior labral repair and capsular plication provided significant clinical improvement with low recurrence and revision rate.

Arthroscopic Double Shoelace Capsular Plication Technique for the Treatment of Borderline Hip Dysplasia Associated With Capsular Laxity

Hip arthroscopy is an innovative surgical tool that is minimally invasive; however, the working space is very limited because of small surgical wounds. Recent literature has shown that capsular repair after capsulotomy during hip arthroscopy facilitates the restoration of hip joint stability. Previous Technical Notes have introduced the shoelace capsule closing technique using a single Ultratape. However, even with the shoelace capsule closing technique, we periodically have encountered difficult cases with extensive capsular laxity. In this Technical Note, we introduce an improved hip capsule plication technique using 2 pieces of Ultratape for treating borderline hip dysplasia with capsular laxity. This double shoelace capsule plication technique theoretically reduces tearing risks during closure of delicate and fragile capsules. Level of evidence: 1 (hip); 2 (other).

Arthroscopic Capsular Plication in Patients With Labral Tears and Borderline Dysplasia of the Hip: Analysis of Risk Factors for Failure

Background: Hip arthroscopy for the treatment of instability in the setting of borderline dysplasia is controversial. Capsular management in such cases is an important consideration, and plication has been described as a reliable technique, with good midterm outcomes reported when indications are appropriate. Hypothesis: Patients with borderline dysplasia who have a lower lateral center-edge angle (LCEA) and greater age will be at a higher risk of failure after arthroscopic capsular plication. Study Design: Case-control study; Level of evidence, 3. Methods: Data were retrospectively reviewed for all patients between 15 and 40 years of age who underwent hip arthroscopy from November 2008 to January 2015. Inclusion criteria were an LCEA between 18° and 25°, Tönnis grade ≤1, primary case with capsular plication, and minimum 2-year follow-up. Patients were excluded if they had any history of ipsilateral hip procedure or conditions such as Legg-Calve-Perthes disease, slipped capital femoral epiphysis, rheumatologic disease, and Tönnis grade ≥2. Age, sex, and body mass index data were retrieved for each patient. Patient-reported outcomes (PROs)—including modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Sports Specific Subscale, and a visual analog scale (VAS) for pain (0-10)—were obtained preoperatively and at a minimum of 2 years postoperatively, in addition to the postoperative International Hip Outcome Tool–12. The “success” group consisted of all patients who achieved the patient acceptable symptomatic state of mHHS ≥74 and had no ipsilateral hip surgery subsequent to their index arthroscopy. The “failure” group was composed of patients who were below the patient acceptable symptomatic state at latest follow-up or required secondary arthroscopy or conversion to total hip arthroplasty. Patient satisfaction and minimal clinically important difference were also calculated. Mean age for the failure group was applied as a cutoff age for subanalysis, and relative risk for failure was determined. Results: Ninety patients (97 hips; 79.5%) met criteria for the success group, and 25 patients (25 hips) met criteria for the failure group. No significant differences in preoperative baseline scores or VAS were found. However, there did appear to be a trend that the failure group had lower mean preoperative scores for all PRO measures and a higher VAS score. The differences in preoperative mHHS and NAHS closely approached significance (P = .053). Postoperative PRO, VAS, and patient satisfaction scores of the success group were significantly higher than the failure group. The failure group was significantly older than the success group (28.5 ± 7.8 vs 23.5 ± 7.5 years, P = .005). Patients >35 years old were 2.25 times more likely to fail according to relative risk (95% CI, 1.10-4.60; P = .0266). LCEA did not differ between the groups, and no other risk factors for failure were identified. Conclusion: Stringent criteria for patient selection and meticulous repair or augmentation of the static stabilizers of the hip yielded favorable clinical outcomes in this study cohort with borderline dysplasia. Within this carefully selected group, the analysis revealed that increased age was the main risk factor for failure in the management of borderline hip dysplasia via isolated primary arthroscopic hip surgery with capsular plication.

Multidirectional Instability of the Shoulder: Treatment Options and Considerations.

Multidirectional instability (MDI) is a debilitating condition that involves chronic subluxation or dislocation of the shoulder in >1 direction. Numerous proposed mechanisms of MDI exist, which occurs in the setting of redundant capsular tissue. Symptoms can range from recurrent dislocations or subluxations to vague aching pain that disrupts activities of daily living. Magnetic resonance imaging is often performed during evaluation of this condition, although magnetic resonance arthrography may provide more detailed images of the patulous capsule. In the absence of a well-defined traumatic cause, such as a labral tear, initial treatment for MDI is a structured rehabilitation program with exercises aimed at strengthening the rotator cuff and periscapular muscles to improve scapular kinematics. Patients with recalcitrant symptoms may benefit from surgical stabilization, including open capsular shift or arthroscopic capsular plication, aimed at decreasing capsular volume and improving stability.

Corrective Posterior Opening-wedge Glenoid Neck Osteotomy for Excessive Retroversion

Excessive retroversion of the glenoid can cause eccentric loading of the glenohumeral joint and may lead to posterior shoulder instability, posterior labral tears, functional impairment, static posterior shoulder subluxation, and progressive glenohumeral arthropathy. For young patients surgical options are limited and include open labral repair and capsular plication, arthroscopic labral repair and capsular plication, or open posterior opening-wedge glenoid osteotomy. Of these, only the osteotomy can correct the glenoid retroversion and recenter the humeral head. Here, we detail our preoperative work-up, the surgical technique and the postoperative protocol for a corrective posterior opening-wedge corrective glenoid osteotomy. Multiple studies have showed that children, adolescents, and young adults with severe glenoid retroversion may benefit from this treatment. This surgery is technically challenging and should have narrow surgical indications. Patients can demonstrate improved radiographic bony architecture of the glenohumeral joint, diminished pain, and improved function.

Surgical stabilization for first-time shoulder dislocators: a multicenter analysis

Anterior shoulder dislocations in young patients are associated with high rates of recurrent instability. Although some surgeons advocate for surgical stabilization after a single dislocation event in this population, there is sparse research evaluating surgical treatment for first-time dislocators. Patients undergoing surgical stabilization for anterior shoulder instability were prospectively enrolled at multiple institutions from 2015-2017 and stratified by number of dislocations before surgery. Demographic data, preoperative patient-reported outcomes, imaging findings, surgical findings, and procedures performed were compared between groups. Analysis of variance, χ2, and multivariate logistic regression were used for statistical analysis. The study included 172 patients (mean age, 25.3 years; 79.1% male patients) for analysis (58 patients with 1 dislocation, 69 with 2-5 dislocations, 45 with >5 dislocations). There were no intergroup differences in demographic characteristics, preoperative patient-reported outcomes, or physical examination findings. Preoperative imaging revealed increased glenoid bone loss in patients with multiple dislocation events (P = .043). Intraoperatively, recurrent dislocators were more likely to have bony Bankart lesions (odds ratio [OR], 3.26; P = .024) and biceps pathology (OR, 6.27; P = .013). First-time dislocators more frequently underwent arthroscopic Bankart repair and/or capsular plication (OR, 2.22; P = .016), while recurrent dislocators were more likely to undergo open Bristow-Latarjet procedures (OR, 2.80; P = .049) and surgical treatment for biceps pathology (OR, 5.03; P = .032). First-time shoulder dislocators who undergo stabilization are more likely to undergo an arthroscopic procedure and less likely to have bone loss or biceps pathology compared with recurrent dislocators. Future studies are needed to ascertain long-term outcomes of surgical stabilization based on preoperative dislocation events.

Predictors of Poor Clinical Outcome After Arthroscopic Labral Preservation, Capsular Plication, and Cam Osteoplasty in the Setting of Borderline Hip Dysplasia

Background: Borderline developmental dysplasia of the hip (BDDH) is frequently diagnosed concurrently with cam impingement. While hip arthroscopy has advanced the treatment of hip joint pathology, including femoroacetabular impingement (FAI), arthroscopic treatment for FAI in the setting of BDDH remains a challenge amid a subset of patients. The risk factors of poor clinical results after hip arthroscopic labral preservation and FAI corrections in the setting of BDDH patients have not been well established. Hypothesis: Pre- and intraoperative findings can predict the poor clinical outcomes after hip arthroscopic surgery for FAI in the setting of BDDH. Study Design: Case control study; Level of evidence, 3. Methods: Of patients with BDDH (defined as lateral center edge [LCE] angle between 20° and 25°) who underwent arthroscopic procedures for FAI between 2009 and 2014, 45 met inclusion criteria (45 hips: 15 males and 30 females). Their mean age was 31.4 years (range, 12-65 years), and the mean LCE angle was 23.2°. Clinical and radiographic follow-up evaluations up to a minimum of 2 years after surgery were performed for all patients. Failure of the procedure was defined as conversion to subsequent surgery or having a Tönnis osteoarthritis grade of 2, and success was defined as patients who did not need subsequent surgery. Univariate analysis and Cox hazard proportional analysis were performed for both cohorts. Results: Of 45 patients, 11 (24%) had revision surgery (endoscopic shelf acetabuloplasty for 5 patients, total hip arthroplasty for 2, and revision hip arthroscopy for 2) or advanced to Tönnis grade ≥2 osteoarthritis and thus constituted the failure group. In the success group, modified Harris Hip Score (median, pre- vs postoperative: 72.1 vs 100, P< .001, Wilcoxon signed-rank test) and nonarthritic hip score (58.8 vs 98.8, P< .001) were significantly improved at the minimum 2-year follow-up. The median age of the failure group was significantly higher than that of the success group (47.0 vs 20.0, P< .001, Mann-Whitney Utest). Risk factors of poor clinical outcomes were identified as follows: age ≥42 years (hazard ratio [HR], 11.6; 95% CI, 2.5-53.9; P= .002, Cox hazard model), broken Shenton line (HR, 6.4; 95% CI, 1.9-22.3; P= .003), Tönnis angle ≥15° (HR, 3.9; 95% CI, 1.2-12.9; P= .03), vertical center anterior (VCA) angle ≤17° (HR, 5.0; 95% CI, 1.5-17.1; P= .01), Tönnis grade 1 at preoperative radiograph (HR, 3.6; 95% CI, 1.1-11.7; P= .04), severe cartilage delamination at acetabulum (HR, 11.8; 95% CI, 3.0-46.1; P< .001), and mild cartilage damage at femoral head (HR, 8.1; 95% CI, 2.1-30.8; P= .002). Conclusion: Preoperative predictors of poorer outcomes from hip arthroscopic labral preservation, capsular plication, and cam osteoplasty in the setting of BDDH are age ≥42 years old, broken Shenton line, osteoarthritis, Tönnis angle ≥15°, and VCA angle ≤17° on preoperative radiographs. Intraoperative predictors of poorer outcomes are severe acetabular chondral damage and even mild femoral chondral damage. Although the patients in the setting of BDDH may have good outcomes from isolated hip arthroscopy, caution is suggested for those with the aforementioned risk factors.

Multidirectional Shoulder Instability: Treatment.

Background:The treatment of multidirectional instability of the shoulder is complex. The surgeon should have a clear understanding of the role of hiperlaxity, anatomical variations, muscle misbalance and possible traumatic incidents in each patient.Methods:A review of the relevant literature was performed including indexed journals in English and Spanish. The review was focused in both surgical and conservative management of multidirectional shoulder instability.Results:Most patients with multidirectional instability will be best served with a period of conservative management with physical therapy; this should focus in restoring strength and balance of the dynamic stabilizers of the shoulder. The presence of a significant traumatic incident, anatomic alterations and psychological problems are widely considered to be poor prognostic factors for conservative treatment. Patients who do not show a favorable response after 3 months of conservative treatment seem to get no benefit from further physical therapy.When conservative treatment fails, a surgical intervention is warranted. Both open capsular shift and arthroscopic capsular plication are considered to be the treatment of choice in these patients and have similar outcomes. Thermal or laser capsuloraphy is no longer recommended.Conclusion:Multidirectional instability is a complex problem. Conservative management with focus on strengthening and balancing of the dynamic shoulder stabilizers is the first alternative. Some patients will fare poorly and require either open or arthroscopic capsular plication.

Arthroscopic Pancapsular Shift With Labral Repair for Multidirectional Instability of the Shoulder

Initial treatment of shoulder multidirectional instability (MDI) consists of nonoperative modalities of physical therapy and rehabilitation; if this fails, surgical treatment can become necessary. MDI of the shoulder can be challenging to manage in individuals who fail conservative management. Historically, surgical treatment for MDI has been open capsular plication; however, arthroscopic capsular plication has now become the standard of care, with outcomes similar to the open procedure. The purpose of this article and Video 1 is to describe our arthroscopic technique for pancapsular shift with labral repair.