If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Address correspondence to Ivan H. Wong, M.D., M.A.C.M., F.R.C.S.(C.), Dalhousie University, 5955 Veterans' Memorial Lane, Camp Hill Veterans' Memorial Building, Room 2106, B3H2E1, Halifax, Nova Scotia, Canada.
Recurrent multidirectional shoulder instability is a difficult clinical problem. This can be compounded in patients with connective tissue diseases such as Ehlers-Danlos syndrome. We present an all-arthroscopic technique involving extra-articular anterior and posterior glenoid bone grafting to augment a capsular repair in a patient with Ehlers-Danlos syndrome and recurrent multidirectional shoulder instability. Graft options include either distal tibial allograft or iliac crest autograft. Anterior graft placement uses a dilated far medial portal using an inside-out technique. The posterior graft is placed through a dilated posterior portal. A 1-mm edge of anterior and posterior glenoid rim is denuded of cartilage for later capsular repair, and grafts are secured flush to the osseous surface. A capsular plication is then completed and repaired to the prepared native glenoid surface, using the grafts as extra-articular osseous bumpers.
See video under supplementary data.
We present an all-arthroscopic technique involving anterior and posterior capsular plication with extra-articular glenoid bone grafting to treat a patient with Ehlers-Danlos syndrome and recurrent multidirectional instability of the shoulder. Nonoperative measures were exhausted prior to surgical intervention. We prefer this technique as it preserves the subscapularis muscle and coracoid-conjoint complex while combining soft-tissue and osseous support to treat a difficult patient population.
Positioning and Preparation
The patient was placed in the semilateral position by rolling 30° posteriorly to make the glenoid surface parallel with the floor (Table 1). This position allows for easier placement of glenoid graft screws later in the procedure. Both the arm and ipsilateral hip were prepped and draped in the usual fashion. The arm was abducted 60° in balanced traction using a pneumatic arm holder (Spider 2; Smith and Nephew, Memphis, TN).
Table 1Operative Pearls
Lateral decubitus position, leaning back slightly to allow the glenoid to be placed horizontal with the floor.
Drape out patient to midline anteriorly and just until the medial edge of scapula posteriorly (to be able to fully create the anterior and posterior portals).
Save all capsule-labral tissue from both anterior and posterior glenoid rims as multidirectional instability (MDI) will need plication as well as boney augment to minimize chance for recurrence.
Bone graft measurements to compare with cadaveric values (best measure from intra-articular findings). For MDI, the goal is to make glenoid 120% of normal size to limit dislocations.
Medial portal creation from inside-out technique: quick, safe, reproducible.
Retractor to help viewing of posterior bone grafting position.
Use finger in the posterior portal to assess posterior graft position, which helps to ensure both are visually and tactilely flush with glenoid.
Capsule plication sutures to help soft-tissue tensioning at end of case on top of the increased bone volume of the glenoid (capsule to decrease subluxation, bone to decrease dislocation).
Skin landmarks and diagnostic portals are placed in standard fashion for shoulder arthroscopy with the addition of an enlarged anterior medial portal (Fig 1). A standard posterior portal is created, keeping slightly medial in order to remain parallel with the glenoid face (Fig 2). From the anterior superior (AS) portal, assessment of glenoid bone quality, Hills-Sachs defect volume, anterior capsule, resection of the rotator interval, and anterior glenoid neck debridement are carried out.
A thermal probe (Dyonics RF-S Whirlwind 90° probe, Smith and Nephew) is used to perform a complete release of the rotator interval. This step is important for allowing passage of the anterior graft and visualization of the coracoid process and conjoint tendon, necessary landmarks for development of the far medial (M) portal.
After preparing the glenoid similarly to a standard Bankart repair, a small curette is used to remove 1 mm of anterior glenoid rim cartilage for later capsular repair to bone. The posterior glenoid labrum and neck are released and prepared from the 10 to 6 o'clock positions in a similar fashion using the anteroinferior portal. Using a calibrated probe, the glenoid defect size is determined and compared with preoperative computed tomography measurements (Fig 3).
The far M portal is created using an inside-out technique.
To release tension and medialize the conjoint tendon, the elbow is flexed to 90°, and the arm is adducted to neutral. A switching stick is then placed through the posterior portal, parallel to the glenoid surface and superior to the subscapular muscle. The switching stick is kept lateral to the conjoint tendon as it is advanced through the deltoid muscle to protect the neurovascular structures. The skin is opened over the top of the switching stick and followed by slotted cannula retractors (Smith and Nephew). A large channel dilator is then passed through the slotted cannula for anterior graft placement and screw fixation (Depuy Synthes, Latarjet set, Raynham, MA). The M portal must be parallel to the anterior glenoid neck for proper graft positioning. The posterior portal is dilated in a similar fashion using the slotted cannula and channel dilator prior to posterior graft placement.
Iliac Crest Harvest and Graft Preparation
Tricortical graft is required for an adequate anterior and posterior structural glenoid bumper. Iliac crest is harvested in standard fashion, with the size based on interoperative arthroscopic measurements. Grafts are skeletonized of any soft tissue. A microsagittal saw is used to cut grafts to appropriate dimensions. The anterior graft measured 10 × 20 × 15 mm, and the posterior graft measured 5 × 20 × 15 mm. The DePuy Mitek Bristow-Latarjet Instability Shoulder System (DePuy Synthes, Mitek) is used. Two k-wires are placed through the alpha-beta guide in the appropriate position for screw angulation (Fig 4). The k-wires are then overdrilled and tapped. The drill holes are filled with top-hat washers and then secured into place to help reduce hoop stress and prevent graft fracture. The prepared grafts are then secured in place with the double-barrel cannula
Using the AS viewing portal, a small switching stick is placed through the posterior portal to retract the subscapular muscle inferiorly. The graft and double-barrel cannula are passed between the slotted cannulas through the M portal. The lateral surface of the graft should be flush or slightly medial to the glenoid bone surface (Fig 6). The superior k-wire is secured in place to allow for fine-tuning of graft alignment followed by the second k-wire. The graft should then be viewed from multiple portals to ensure optimal placement. A 2.8-mm calibrated cannulated drill is used to drill over the k-wires. Screw length is measured off the drill as it perforates the posterior glenoid cortex. Two titanium 3.5-mm cannulated screws are passed over the top of the guide wires (Fig 7). The subscapular muscle with attached capsular/labral complex is then reduced back into place.
The posterior graft is placed in a similar sequence of steps. The AS viewing portal is still used, but the graft is now placed through the slotted cannula in the dilated posterior portal. The graft is visually confirmed to be at or slightly medial to the glenoid bone surface. Visualization of graft placement can be challenging, and we have found that a switching stick placed through the anteroinferior portal can be used to lift the posterior capsule laterally to improve visibility. Due to the limited bone volume of the glenoid neck, screw convergence with anterior screws is a risk. Care should be taken with k-wire placement to avoid this problem. The 2.8-mm calibrated cannulated drill is used to drill over the k-wires, and screw lengths are measured off the drill. Two titanium 3.5-mm cannulated screws are passed over top of guide wires and observed as they compress the graft to the bone.
The posterior capsular repair is completed first with the arm positioned in 60° of abduction. The capsular/labral complex is repaired to the site of the patient's native glenoid, leaving the graft extra-articular. Percutaneous suture anchor placement is established, followed by impaction of the suture anchor (1.4 mm Linvatec All-Suture Y-knot anchor; Linvatec, Largo, FL). A suture passer (Smith and Nephew Accu-Pass suture passer) is then used to shuttle sutures through the redundant capsule and labrum. For the posterior capsular repair, 2 anchors are placed in the 7 and 9 o'clock positions.
Anterior capsular/labral complex repair and plication is done in a similar fashion at the edge of the patient's native glenoid. One to 2 millimeters of articular surface was previously removed with a small curette to create a bony surface for capsular healing. As with the posterior repair, the anterior bone block is left extra-articular. Three to 4 suture anchors are then used to span the length of graft (Fig 8). Soft tissue is balanced to reduce the humerus over the center of the glenoid.
Traditional stabilization procedures depend on tightening the anterior structures and recreating the labral bumper. In patients with connective tissue disease, tightening the anterior capsule and soft tissue may not provide enough stability and may stretch over time. By adding bony augmentation to the glenoid and increasing the available surface area for contact, the shoulder can be stabilized in a way that is more resistant to change.
Shoulder instability with associated bone loss has been shown to respond well to bony augmentation.
We present this technique for surgical management of Ehlers-Danlos syndrome with both anterior and posterior shoulder instability. A multitude of surgical treatment options for shoulder multidirectional instability (MDI) have been reported with varying results
(Table 2). Open inferior capsular shift, arthroscopic capsular plication, and thermal capsulorrhaphy are the most commonly used techniques for MDI treatment, with inferior clinical results noted post-treatment.
As previously shown, the arthroscopic technique allows for anatomic placement of the graft with excellent visualization to ensure that the graft and articular surface are parallel. This technique also allows for graft placement without damage to the subscapularis tendon by mobilizing and retracting, as opposed to splitting the tendon. Inserting the graft through the rotator interval can be done with minimal soft-tissue dissection. By placing the M portal lateral to the conjoint tendon, the neurovascular structures are protected, allowing for safe passage of the graft and all hardware through the anterior soft tissues.
This minimally invasive technique allows for the combined advantage of extra-articular anterior and posterior osseous support with the volume-reducing effect of arthroscopic capsular plication. Although technically demanding, we feel this technique is a viable option for a difficult patient population and may offer improved clinical outcomes. This will be elucidated with larger clinical volumes.
Arthroscopic technique for anterior and posterior extra-articular glenoid bone grafting for multidirectional instability in a young female patient with Ehlers-Danlos syndrome. The iliac crest autograft was used for bone graft. The patient is placed in the lateral decubitus position, and the operative shoulder is the left side. The procedure is started using a standard posterior portal. The anterosuperior portal and anteroinferior portals are then made in the standard fashion. Following this, a far medial portal is created using an inside-out technique. The majority of the video is viewed from the anterosuperior portal. Important steps of the surgical technique are presented.
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.