Inferior Capsule Research Articles

Technique for selecting capsular tightness in repair of anterior-inferior shoulder instability.

Part I of our study consisted of sending a survey questionnaire to all members of the American Shoulder and Elbow Surgeons in which specific questions were asked about their technique of surgical repair in patients with anterior instability who had capsular laxity or injury in conjunction with marked inferior laxity. Part II is a description of the technique and preliminary results in 18 patients of a modified anterior-inferior capsular shift technique that tightens the inferior capsule with the shoulder positioned in abduction and external rotation and the superior capsule with the shoulder in adduction and external rotation. Of the members of the Society of the American Shoulder and Elbow Surgeons who responded to the survey, 80% agreed that preservation of external rotation was important and that shoulder position at the time of capsular repair might influence the ultimate range of motion obtained. However, no more than 50% of the respondents agreed on any one position for the arm when repairing the capsule. The most common responses for each position were flexion 0 degrees (49%) (range, 0 degrees to 40 degrees), abduction 30 degrees (24%) (range, 0 degrees to 80 degrees), and external rotation 30 degrees (37%) (range, 0 degrees to 70 degrees). The average postoperative follow-up period for the 18 patients was 27 months (range, 24 to 39 months). Of the 18 patients, 11 (61%) maintained symmetric motion; the others had minimal loss of external rotation compared with that of the contralateral shoulder. Six of eight patients with repair on the dominant side were able to return to full premorbid recreational throwing or racquet sports, and seven with repair on the nondominant side returned to full participation in overhead sports such as basketball and swimming. We conclude that this method of "selective" capsular repair may be a useful guideline to gauge the degree of capsular tightening in patients who have capsular injury or laxity.

Surgical treatment of posterior instability of the shoulder with the posterior-inferior capsular shift

Surgical Principles The posterior-inferior capsular shift is performed to treat recurrent glenohumeral instability that has failed to respond to conservative therapy. Through a posterior approach, the excessively redundant posterior and inferior joint capsule is shifted superiorly to reduce excessive capsular volume. The extent of the lateral capsular dissection inferiorly, as well as the amount of tissue shifted, can be tailored to fit the degree and location of the laxity. When the posterior labrum is found to be detached, it is reattached to the glenoid rim before proceeding with the posterior capsulorrhahy. Bony augmentation of the repair is needed in only rare cases, i.e. in glenoid hypoplasia or in revision capsulorrhaphy procedures.

The pattern of the collagen fiber bundles of the capsule of the glenohumeral joint

The macroscopic anatomy and the architecture of the collagen fiber bundles were studied in the joint capsules of 43 cadaver shoulders. All the specimens were transilluminoted by polarized light after preparation by Spalteholz' technique. Areas of high-fiber density and complex structure were examined histologically. The macroscopically recognizable ligaments are composed of collagen fiber bundles in several layers of differing thickness and orientation. A simple pattern of radial and circular fibers is found only in the relatively thin posterior capsule. A complex pattern of cross-linking was visible in the superior capsule, and a system of fiber bundles spirally crossing each other was present in the anterior/inferior capsule. The examination under polarized light revealed a continuous transition between the ligamentous reinforcements at the anterior inferior capsule, which radiated obliquely from the glenoid rim and varied greatly in form and orientation. The complicated structure of the joint capsule would suggest that the capsular cylinder has to be regarded as a functional entity and that the current biomechanical concepts must be modified if we want to understand its stabilizing effect. The structural features of the superior capsule present new insight about the pathogenesis of rotator cuff tearing, which can develop as a result of shearing stress between the capsular and tendinous layers.

Titanium staple and screw fixation for recurrent dislocation of the shoulder

A small titanium staple with a locking screw was designed in 1979 to hold the anterior capsule of the shoulder firmly to the front of the scapula just medial to the glenoid. The posterior or inferior capsule can also be stabilized. Two indentations on the staple diminish capsular compression, while a central hole for a 4.5-mm titanium alloy cortical screw allows firm fixation of the staple. A small deltopectoral or axillary approach is used and the subscapularis and capsule are incised on the line of the muscle fibres. The operation is relatively simple and combines the advantages of a Bankart, bone block and capsular plication in a single small operative procedure. Full movement, including external rotation, can be started 3 days postoperatively, and most patients can return to manual labour or contact sport in 4 to 6 weeks. A total of 47 anterior dislocations and two posterior dislocations have been treated since 1981, including six failed Putti-Platt operations and one Helfet operation. Full shoulder movement is usually achieved within 3 weeks of operation.

Capsular properties of the shoulder.

The purpose of this study was to determine the structural properties of the capsule of the glenohumeral joint. Twelve fresh frozen cadaveric shoulders were studied. Capsular strips were prepared from four different sites (anterior, posterior, superior, and inferior) of the capsule. One end of the capsular sections was left attached to the humerus, and the other excised was fixed in a clamp of an Instron universal testing machine. Maximum load, strength (maximum stress), and modulus of elasticity of these four capsular portions were measured. The most common mode of failure was tear at the midsubstance (68%), followed by tear at the clamp-capsule junction (23%), and detachment from the humerus (9%). The posterior capsule (1.0 +/- 0.4 mm) was thinner than the anterior (1.8 +/- 0.3 mm), superior (1.6 +/- 0.4 mm), and inferior capsule (1.5 +/- 0.3 mm). Among the four portions of the capsule, the posterior capsule showed the greatest strength (216.6 +/- 58.2 kg/cm2) and modulus of elasticity (683.1 +/- 228.8 kg/cm2), whereas the superior capsule showed the least strength (82.4 +/- 33.5 kg/cm2). There were no significant differences in maximum load. The greater strength of the posterior capsule may be one explanation for the low incidence of posterior shoulder dislocation.

Lumbar facet joint fat pads: their normal anatomy and their appearance when enlarged

The polar recesses, superior and inferior to lumbar facet joints, are filled by fat pads from which fat-filled synovial folds project between the articular surfaces for a distance of two to four millimetres. The intracapsular superior recess lies between the ligamentum flavum and the lamina above. The extracapsular inferior recess lies on the back of the lamina below and communicates with the joint through a hole in the inferior capsule. The intracapsular folds move freely in and out of the joint during movements. These features are demonstrated in anatomic studies using transverse sections and radiologic studies using computed tomography. In about 4% of lumbar spines examined, the intraarticular fat pads are enlarged and extend from the joint recess(es) into the middle third of one or more facet joints. The fat pads can be identified in CT scans by their radiolucency and distinguished from vacuum phenomenon by measuring their attenuation values. The cause of the intra-articular enlargement of the fat pads is unknown, but it is suggested that their extension into the middle third of the joint may be secondary to degenerative change in the motion segment with capsular laxity in the affected joint.

Phacofracture: A Small Incision Extracapsular Surgery Technique without Phaco-emulsification

The phacofracture technique is designed to remove nuclear fragments manually through a 6 mm or smaller incision. It is a viscoelastic-dependent technique. A capsulotomy can be performed through a small opening in a previously made, straight, tangential, limbal scleral groove. The nucleus is partially loosened by a vertical seesaw manoeuvre. A vertical nucleus groove is fashioned with the tip of the cystotome. Hydrodissection completes the loosening of the nucleus. The irrigating cyclodialysis tip is inserted beneath the inferior anterior capsule and the edges of the nucleus are hydrodissected. The superior pole of the nucleus is subluxed using a blunt probe plus additional hydrodissection. Nuclear splitting is performed with the use of two instruments: one is the solid vectis positioned behind the nucleus; the other is a knife-edged instrument which is positioned in the pre-existing groove and pressed deliberately through the nucleus. This is a very slow and gentle step. The two nuclear halves are slightly separated with the nucleotome to create a passage for the forceps. The anterior chamber is further stabilized with viscoelastic. An extra small bolus of viscoelastic is insinuated between the endothelium and anterior surface of the nuclear fragments for an extra margin The forceps are then slowly passed into the anterior chamber. If the nuclear fragments are asymmetrical, the smaller of the two fragments is removed first. With forceps retracting the anterior lip, the first nuclear fragment is slowly removed. After further stabilization of the anterior chamber with more viscoelastic material, the remaining fragment is grasped and slowly extracted. Using an VA handpiece with a 0.5mm aspirating orifice, the nuclear debris is removed. This debris, admixed with the viscoelastic material, makes an exceptionally tenacious, stubborn mixture and is aspirated best with a larger opening. The residual cataractous cortex can now be aspirated in a customary fashion with a 0.3 mm tip. Following completion of the removal of the cortex, a posterior chamber lens is implanted in the capsular sac. The 6 mm incision is closed with two 8-0 polyglycolic sutures. The closure is completed with a central 10-0 nylon 'X' suture with the knot buried in the wound. The 10-0 nylon then remains after the polyglycolics are absorbed. This enhances astigmatism control.

Treatment of failed open reduction for congenital dislocation of the hip.

Twenty-three patients with 25 involved hips underwent repeat open reduction after previous unsuccessful attempts at open reduction for congenital dislocation of the hip (CDH). All hips ultimately were reduced at a mean age of 2 years 10 months (range 10 months to 7 years 3 months). On review, we noted that 15 of the hips were never concentrically reduced at the first procedure, and seven of these hips had undergone simultaneous Salter osteotomy. The most common cause of failure was improper exposure and release of the tight inferior capsule and transverse acetabular ligament, which blocked complete reduction. A vascular necrosis was documented in 44% of the hips, with a lateral physeal growth disturbance in four hips, a central physeal growth arrest in four hips, and complete femoral head necrosis in three hips.

Anatomy of the Axillary Nerve and Its Relation to Inferior Capsular Shift

Axillary nerve injury is a recognized complication of the capsular slide procedure for multidirectional instability of the shoulder. Axillary nerve dissection followed by an anterior or posterior capsular shift procedure was carried out on 12 autopsy subjects to observe: (1) the normal relationships of the nerve; (2) its proximity to structures dissected in the procedure; and (3) the effects upon it of both anterior and posterior capsular shift procedures. The axillary nerve arises immediately posterior to the coracoid process and conjoint tendon. It crosses the inferolateral border of the subscapularis 3 to 5 mm medial to its musculotendinous junction, and it lies in intimate contact with the inferior capsule as it passes through the quadrilateral space. The nerve should be visualized prior to transecting the subscapularis tendon. During detachment of the inferior capsule from the humeral neck, the humerus should be gradually externally rotated, and the nerve should be gently retracted with a small flat instrument. Sutures reattaching the flap should be carefully placed to avoid injuring the nerve. The tendinous insertion of the teres minor is preserved from a posterior approach. The nerve can be visualized and protected during capsular detachment.

IMMUNOHISTOCHEMICAL DEMONSTRATION OF NOCICEPTORS IN THE CAPSULE AND SYNOVIAL FOLDS OF HUMAN ZYGAPOPHYSEAL JOINTS

Substance P, a physiologically potent neuropeptide, is considered to participate in nociceptive transmission of nerve impulses. Substance P immunofluorescent nerves are demonstrated in the inferior joint recess capsule and its synovial folds in human lumbosacral zygapophyseal joints. This may have clinical significance in spinal pain.

PAPAIN-INDUCED DEGENERATIVE ARTHRITIS OF THE HIP IN RABBITS

1. Degenerative arthritis has been produced consistently in adult rabbits by the injection of the proteolytic plant enzyme papain into the hip joint. Arthritic changes were recognisable radiographically after six weeks. 2. A progression of changes occurred, from loss of acid mucopolysaccharide staining in the matrix, fibrillation, fissuring and erosion of articular cartilage with death of chondrocytes in the weight-bearing areas, to secondary bony changes of subchondral sclerosis, occasional cysts and osteophyte formation. 3. Synovial inflammation occurred with accumulation of cartilage and bone debris in the inferior capsule and later capsular thickening. 4. It is suggested that this arthritis is sufficiently similar to human osteoarthritis to be useful as a model for further studies of the pathogenesis of the disease and the effects of different methods of treatment.